Serving Substance Abuse Professionals Since 1993

Last Update: 27.11.11

C O R K O N L I N E

powerpoint presentations
CORK database search
resource materials
bibliographies
clinical tools
user services
newsletters
about cork
home

CORK Bibliography: Substance Use and Chronic Mental Illness

93 citations. January 2009 to present

Prepared: December 2011

Baker AL; Hides L; Lubman DI. Treatment of cannabis use among people with psychotic or depressive disorders: A systematic review. (review). Journal of Clinical Psychiatry 71(3): 247-254, 2010. (36 refs.)

Objective: This article systematically reviews the evidence from randomized controlled trials (RCTs) for pharmacologic and psychological approaches to the treatment of cannabis use among individuals with psychotic or depressive disorders. Data Sources: A systematic literature search was conducted using the Pub Med and PsychINFO data-bases from inception to December 2008. Individual searches in cannabis use (search terms: marijuana, cannabis, marijuana abuse, cannabis abuse, marijuana usage, cannabis usage), mental disorders (search terms: mood disorders, affective disorders, anxiety disorders, anxiety, depressive disorder, depression, psychotic disorders, psychosis, mental disorders), and pharmacotherapy (search terms: medication, drug therapy, pharmacotherapy, psychopharmacology, clinical trials, drug trial, treatment trial) were conducted and limited to humans, adolescents and adults. Study Selection: A search combining the individual cannabis use, mental disorder and pharmacotherapy searches produced 1,713 articles (PubMed = 1,398; PsychINFO = 315). Combining the cannabis use and mental disorder searches while limiting them to English articles and RCTs produced a total of 286 articles (PubMed = 228; PsychINFO = 58). From this literature, there were 7 RCTs conducted among mental health clients that reported cannabis use outcomes using pharmacologic or psychological interventions. Data Synthesis: While few RCTs have been conducted, there is evidence that pharmacologic and psychological interventions are effective for reducing cannabis use in the short-term among people with psychotic disorders or depression. Conclusions: Although it is difficult to make evidence-based treatment recommendations due to the paucity of research in this area, available studies indicate that effectively treating the mental health disorder with standard pharmacotherapy may be associated with a reduction in cannabis use and that longer or more intensive psychological interventions rather than brief interventions may be required, particularly among heavier users of cannabis and those with more chronic mental disorders. Specific recommendations regarding the type and length of specific psychological treatments cannot be made at this time, although motivational interviewing and cognitive-behavioral therapy approaches appear most promising.

Baker A; Richmond R; Castle D; Kulkarni J; Kay-Lambkin F; Sakrouge R et al. Coronary heart disease risk reduction intervention among overweight smokers with a psychotic disorder: Pilot trial. Australian and New Zealand Journal of Psychiatry 43(2): 129-135, 2009. (26 refs.)

Objective: The aim of the present pilot study was to test the feasibility and short-term impact of a multi-component risk factor intervention for reducing (i) coronary heart disease (CHD) risk; (ii) smoking; and (iii) weight among smokers with psychosis. Secondary dependent variables included physical activity, unhealthy eating, substance use, psychiatric symptomatology, treatment retention, general functioning, and quality of life. Method: This was a feasibility study utilizing a pre-post-treatment design with no control group (n=43). All participants provided written informed consent and were assessed before treatment and again a mean of 19.6 weeks later. The treatment consisted of nine individual 1 h sessions of motivational interviewing and cognitive behaviour therapy plus nicotine replacement therapy, in addition to treatment as usual. Research assistants who had not been involved in the delivery of the treatment programme conducted post-treatment assessments. Results: The intervention was associated with significant reductions in CHD risk scores, smoking and weight. A significant improvement was also reported in level of moderate physical activity, and a small change in the unhealthy eating index was reported. No improvement in biological measures (cholesterol and blood pressure) was evident. Conclusions: A multi-component CHD risk factor intervention among smokers with psychosis appears to be feasible and effective in the short-term. A randomized controlled trial replicating and extending these findings is warranted.

Baker A; Turner A; Kay-Lambkin FJ; Lewin TJ. The long and the short of treatments for alcohol or cannabis misuse among people with severe mental disorders. Addictive Behaviors 34(10, Special Issue): 852-858, 2009. (45 refs.)

Substance misuse among people with severe mental disorders is very common and has been associated with a number of adverse outcomes. Most trials among people with severe mental disorders have reported general substance misuse outcomes and have argued that longer treatments are likely to be more effective. Such studies have not specifically compared intervention effectiveness for alcohol vs. cannabis misuse. The present paper reports findings from a synthesis of datasets from three randomized controlled trials (N=248) comparing brief (1-session advice or motivational interviewing, MI) and extended (10 sessions MI/cognitive-behaviour therapy; CBT) interventions for substance misuse among people with psychosis or major depression and outcomes are reported separately for alcohol and cannabis use. Whilst there were comparable rates of reduction in alcohol consumption for the BI and intensive MI/CBT, BI tended to be associated with less reduction in cannabis use. A stepped care approach for substance misuse in people with severe mental disorders may help to improve cannabis outcomes, including monitoring of both mental health and substance misuse domains. with interventions stepped up or down according to treatment response. Future studies should evaluate the effectiveness of stepped care approaches.

Banham L; Gilbody S. Smoking cessation in severe mental illness: What works? (review). Addiction 105(7): 1176-1189, 2010. (64 refs.)

Aims: The physical health of people with severe mental illness (SMI) is poor. Smoking-related illnesses are a major contributor to excess mortality and morbidity. An up-to-date review of the evidence for smoking cessation interventions in SMI is needed to inform clinical guidelines. Methods: We searched bibliographic databases for relevant studies and independently extracted data. Included studies were randomized controlled trials (RCTs) of smoking cessation or reduction conducted in adult smokers with SMI. Interventions were compared to usual care or placebo. The primary outcome was smoking cessation and secondary outcomes were smoking reduction, change in weight, change in psychiatric symptoms and adverse events. Results: We included eight RCTs of pharmacological and/or psychological interventions. Most cessation interventions showed moderate positive results, some reaching statistical significance. One study compared behavioural support and nicotine replacement therapy (NRT) to usual care and showed a risk ratio (RR) of 2.74 (95% CI 1.10-6.81) for short-term smoking cessation, which was not significant at longer follow-up. We pooled five trials that effectively compared bupropion to placebo giving an RR of 2.77 (95% CI 1.48-5.16), which was comparable to Hughes et al.'s 2009 figures for general population data; RR = 1.69 (95% CI 1.53-1.85). Smoking reduction data were too heterogeneous for meta-analysis, but results were generally positive. Trials suggest few adverse events. All trials recorded psychiatric symptoms and the most significant changes favoured the intervention groups over the control groups. Conclusions: Treating tobacco dependence is effective in patients with SMI. Treatments that work in the general population work for those with severe mental illness and appear approximately equally effective. Treating tobacco dependence in patients with stable psychiatric conditions does not worsen mental state.

Barrowclough C; Haddock G; Beardmore R; Conrod P; Craig T; Davies L et al. Evaluationing integrated MI and CBT for people with psychosis and substance misuse: Recruitment, retention and sample characteristics of the MIDAS trial. Addictive Behaviors 34(10, Special Issue): 859-866, 2009. (43 refs.)

Major problems with existing RCTs evaluating psychosocial interventions for psychosis and substance misuse have been identified, in particular small sample sizes, high attrition rates, and short follow up periods. With a sample size of 327 and a follow up of 2 years, the MIDAS trial in the UK is to date the largest RCT for people with psychosis and Substance use and is evaluating an integrated MI and CBT ("MiCBT") client therapy. Whilst the outcomes of the study are not yet available, data on recruitment and retention indicate that attrition rates in MIDAS are low and the majority of those allocated to treatment received a substantial number of therapy sessions. Sample characteristics are in line with those reported in epidemiological studies and are indicative of the challenges facing mental health services attempting to manage the client group: Substance use is often longstanding, with frequent use at moderate or severe level and low motivation for change, and seen in the context of low levels of functioning and significant psychopathology. We conclude that this is a methodologically robust study that will have results generalisable to mental health services.

Batki SL; Meszaros ZS; Strutynski K; Dimmock JA; Leontieva L; Ploutz-Snyder R et al. Medical comorbidity in patients with schizophrenia and alcohol dependence. Schizophrenia Research 107(2-3): 139-146, 2009. (30 refs.)

Background: Schizophrenia and alcohol dependence are major risk factors for a variety of medical problems, yet there has been little research on the medical status of patients in whom both conditions coexist. Methods: We assessed the prevalence and severity of medical illness in 80 patients with schizophrenia or schizoaffective disorder and comorbid alcohol use disorders who entered a controlled trial of monitored naltrexone treatment, and analyzed the relationship between medical illness burden and demographic variables, alcohol and other substance use, and psychosis. Participants underwent physical examination, laboratory tests, medical record review and standardized assessments of medical illness burden, alcohol and other substance use, and psychosis. Nested block multiple regression analyses were used to assess the contribution to illness burden made by demographic variables, alcohol and substance use, and psychosis severity. Results: 83% of participants had at least one chronic medical illness, hypertension being the most common (43%). Medical comorbidity in this cohort was more severe than for schizophrenia patients in the CATIE trial (Chwastiak, L. Rosenheck, R., McEvoy, J.P., Keefe, R.S., Swartz, M.S., Lieberman,J.A., 2006. Interrelationships of psychiatric Psychiatryric symptom severity, medical comorbidity, and functioning in schizophrenia. Psychiatric. Services 57(8), 1102-1109.); the prevalence of hypertension, chronic obstructive pulmonary disease, and coronary artery disease, was more than twice greater. Medical illness burden correlated with alcohol use severity, but appeared to be independent of other substance use or psychosis severity. Conclusions: Patients with co-occurring alcohol use disorder may have significantly more medical illness burden than patients with schizophrenia or schizoaffective disorder alone. Interventions to reduce alcohol use may be necessary to lessen medical morbidity. Published by Elsevier B.V.

Bennett ME; Bellack AS; Brown CH; DiClemente C. Substance dependence and remission in schizophrenia: A comparison of schizophrenia and affective disorders. Addictive Behaviors 34(10, Special Issue): 806-814, 2009. (78 refs.)

The present study examined psychiatric functioning, substance use and consequences, and motivation to change in people with schizophrenia and affective disorders and current or remitted cocaine dependence. Data were collected as part of a naturalistic. longitudinal study examining substance use. motivation to change, and the process of change in people with schizophrenia and affective disorders who were currently dependent or in remission from cocaine dependence. We examined the following questions: (1) Do those in remission show better psychiatric functioning than those who are currently dependent? (2) How do people with schizophrenia and current cocaine dependence differ in terms of substance use and consequences from people with schizophrenia in remission and people with affective disorders and current drug dependence? (3) What internal factors and external factors are associated with changes in substance use in schizophrenia and how do these compare to those in nonpsychotic affective disorders? Results: indicated that people with schizophrenia and current dependence reported higher levels of positive and negative symptoms than those in remission. Remission status was related to less use of other drugs, fewer days of drug problems, less distress from drug problems, and more lifetime drug-related consequences. Those with current dependence reported more days of drinking and drinking to intoxication, as well as higher rates of current alcohol use disorders than the remitted group. When compared to those with affective disorders and cocaine dependence, those with schizophrenia and current dependence reported fewer days of problems associated with their drug use, less distress from drug problems, and fewer recent and lifetime consequences associated with their drug use. The schizophrenia dependent group generally showed the lowest readiness to change, fewest efforts being made to change, and lowest confidence in the ability to change. Implications of these findings are discussed.

Bennett DJ; Ogloff JRP; Mullen PE; Thomas SDM; Wallace C; Short T. Schizophrenia disorders, substance abuse and prior offending in a sequential series of 435 homicides. Acta Psychiatrica Scandinavica 124(3): 226-233, 2011. (35 refs.)

Objective: To examine the relationship between committing homicide, the presence of schizophrenia, substance misuse and past criminality. Method: The study employed a data linkage design, using contacts recorded on two statewide databases, one of which recorded public mental health services contacts and the second of which recorded contacts with the police. The estimated rates of schizophrenia disorders, substance abuse and criminal convictions found among a population of 435 homicide offenders were contrasted with estimated rates in two composite comparison samples. Results: Of the 435 offenders, 38 (8.7%) had been diagnosed with a schizophrenia disorder, which was RR 13.11 (95% CI 9.14-18.80) times more likely than a comparison sample. Rates of known substance abuse between homicide offenders with and without schizophrenia and community-dwelling residents with schizophrenia did not differ significantly. However, these rates were higher than those found in the general community. A similar pattern emerged for comparisons regarding offending histories between these same groups. Conclusion: The association between homicidal violence and having a schizophrenia disorder cannot be explained away simply on the basis of either comorbid substance abuse or prior criminal offending.

Bickel WK; Mueller ET. Toward the study of trans-disease processes: A novel approach with special reference to the study of co-morbidity26. Journal of Dual Diagnosis 5(2): 131-138, 2009. (26 refs.)

The objective of this article was to propose a novel approach, referred to as the study of trans-disease processes (TDPs), to the neuroscientific study of disease processes in general and to co-morbid diseases in particular. The features of this approach are outlined; one potential TDP-delay discounting, which may help account for the co-morbidity of cigarette smoking and schizophrenia-is explored; and the concept of TDPs is contrasted with the concept of endophenotypes. TDPs have the potential for a variety of positive impacts on science.

Bobes J; Arango C; Garcia-Garcia M; Rejas J. Healthy lifestyle habits and 10-year cardiovascular risk in schizophrenia spectrum disorders: An analysis of the impact of smoking tobacco in the CLAMORS schizophrenia cohort. Schizophrenia Research 119(1-3): 101-109, 2010. (40 refs.)

Aim: We analysed the impact of tobacco smoking over several healthy lifestyle habits along with the impact on 10-years cardiovascular event (CVE) risk in the CLAMORS schizophrenia cohort. Methods: This analysis was performed within the scope of the CLAMORS study which included consecutive outpatients meeting DSM-IV criteria for schizophrenia spectrum disorder. Beside smoking history, data on usual healthy lifestyle habits included current exercise, saturated fat sparing diet, low-caloric diet, and daily dietary fibre, salt, caffeine and alcohol consumption were recorded. The 10-year CVE risk was calculated with Framingham function. Results: 1704 patients (61.1% male), 18 to 74 years were examined. Prevalence of smoking was 54.54% (95% Cl: 52.16%-56.90%) significantly higher than in age and sex matched general population subjects, 31.51% (31.49%-31.52%): OR = 2.61 (2.37-2.87, p<0.0001). After controlling by confounders smokers showed a 10-year CVE risk excess versus non-smokers of 2.63 (2.16-3.09), p<0.001. Smoking cessation would reduce the likely of high/very high 10-year CVE risk (above 10%) by near 90% [OR = 0.10 (0.06-0.18), p<0.00011. Also, smokers were more likely to consume alcohol daily [4.13 (3.07-5.54), p<0.0001] and caffeine [3.39 (2.72-4.23), p<0.0001] than non-smoker patients with schizophrenia, and less likely to avoid daily consumption of salt [0.58 (0.43-0.78), p<0.0001], saturated fat [0.71 (0.56-0.91), p = 0.006], high fibre diet [0.67 (0.53-0.84), p = 0.001], or to follow a low-caloric diet [0.63 (0.48-0.81), p<0.0001]. Smokers also were less likely to do exercise habitually [0.62 (0.48-0.82, p = 0.001]. Conclusion: Compared with the general population, patients with schizophrenia showed significant higher prevalence of smoking. Smokers who stop smoking would benefit by a near 90% reduction in the likely of 10-year cardiovascular event risk above 10%.

Brown CH; Bennett ME; Li L; Bellack AS. Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders. Addictive Behaviors 36(5): 439-447, 2011. (68 refs.)

Research has documented the significant challenges of engaging individuals with comorbid serious mental illness (SMI) and substance use disorders (SUDS) in substance abuse treatment. To date it is unclear which factors predict treatment initiation and engagement in this group of individuals with SUDs. In this study we conducted two analyses using data from a randomized trial of substance abuse treatment in outpatients with SMI: the first examining predictors (collected during screening) of completing an initial intake assessment and the second examining predictors (collected during the intake assessment) of becoming engaged in treatment. Results indicated that males and those with schizophrenia spectrum diagnoses were less likely to complete the intake assessment. Participants who reported more positive feelings about their family were more likely to engage in substance abuse treatment. Participants who were recently arrested were less likely to engage in treatment. Those who met criteria for current drug dependence were less likely to engage in treatment. Overall, these findings are a useful step in determining factors that predict substance abuse treatment initiation and engagement in individuals with SMI and SUDs.

Buadze A; Stohler R; Schulze B; Schaub M; Liebrenz M. Do patients think cannabis causes schizophrenia? A qualitative study on the causal beliefs of cannabis using patients with schizophrenia. Harm Reduction Journal 7(e-22), 2010. (32 refs.)

Background: There has been a considerable amount of debate among the research community whether cannabis use may cause schizophrenia and whether cannabis use of patients with schizophrenia is associated with earlier and more frequent relapses. Considering that studies exploring patients' view on controversial topics have contributed to our understanding of important clinical issues, it is surprising how little these views have been explored to add to our understanding of the link between cannabis and psychosis. The present study was designed to elucidate whether patients with schizophrenia who use cannabis believe that its use has caused their schizophrenia and to explore these patients other beliefs and perceptions about the effects of the drug. Methods: We recruited ten consecutive patients fulfilling criteria for paranoid schizophrenia and for a harmful use of/dependence from cannabis (ICD-10 F20.0 + F12.1 or F12.2) from the in- and outpatient clinic of the Psychiatric University Hospital Zurich. They were interviewed using qualitative methodology. Furthermore, information on amount, frequency, and effects of use was obtained. A grounded theory approach to data analysis was taken to evaluate findings. Results: None of the patients described a causal link between the use of cannabis and their schizophrenia. Disease models included upbringing under difficult circumstances (5) or use of substances other than cannabis (e. g. hallucinogens, 3). Two patients gave other reasons. Four patients considered cannabis a therapeutic aid and reported that positive effects (reduction of anxiety and tension) prevailed over its possible disadvantages (exacerbation of positive symptoms). Conclusions: Patients with schizophrenia did not establish a causal link between schizophrenia and the use of cannabis. We suggest that clinicians consider our findings in their work with patients suffering from these co-occurring disorders. Withholding treatment or excluding patients from certain treatment settings like day-care facilities or in patient care because of their use of cannabis, may cause additional harm to this already heavily burdened patient group.

Buckley PF; Miller BJ; Lehrer DS; Castle DJ. Psychiatric comorbidities and schizophrenia. (review). Schizophrenia Bulletin 35(2): 383-402, 2009. (203 refs.)

Psychiatric comorbidities are common among patients with schizophrenia. Substance abuse comorbidity predominates. Anxiety and depressive symptoms are also very common throughout the course of illness, with an estimated prevalence of 15% for panic disorder, 29% for posttraumatic stress disorder, and 23% for obsessive-compulsive disorder. It is estimated that comorbid depression occurs in 50% of patients, and perhaps (conservatively) 47% of patients also have a lifetime diagnosis of comorbid substance abuse. This article chronicles these associations, examining whether these comorbidities are "more than chance" and might represent (distinct) phenotypes of schizophrenia. Among the anxiety disorders, the evidence at present is most abundant for an association with obsessive-compulsive disorder. Additional studies in newly diagnosed antipsychotic-naive patients and their first-degree relatives and searches for genetic and environmental risk factors are needed to replicate preliminary findings and further investigate these associations.

Busto A; Souza RP; Lobo DSS; Shaikh SA; Zawertailo LA; Busto UE et al. Cocaine and amphetamine regulated transcript (CART) gene in the comorbidity of schizophrenia with alcohol use disorders and nicotine dependence. (review). Progress In Neuro-Psychopharmacology & Biological Psychiatry 34(6): 834-836, 2010. (20 refs.)

Studies have shown a genetic susceptibility to develop schizophrenia, alcohol use disorders and nicotine dependence. Brain areas related to reward and reinforcement show high expression of the cocaine and amphetamine regulated transcript (CART). Nicotine and alcohol are also able to modulate CART expression in the hypothalamic areas. In this study, we evaluated whether CART variants would influence the predisposition of schizophrenia subjects to alcohol use disorders and nicotine dependence. Clinical and genetic data were obtained from 190 unrelated Caucasian schizophrenia subjects collected at the Centre for Addiction and Mental Health. We found no association of CART variants with alcohol use disorders or nicotine dependence. We found a trend for allelic association of rs11575893 with the heaviness of smoking behaviour (p = 0.057). Our results indicate that genetic variants in the CART gene may not play a major role in the vulnerability of schizophrenia subjects to concurrent alcohol use disorders and nicotine dependence. Additional association studies in independent samples can evaluate whether CART gene is playing a role in the schizophrenia comorbidity with alcohol use disorders and nicotine dependence.

Casadio P; Fernandes C; Murray RM; Di Forti M. Cannabis use in young people: The risk for schizophrenia. (review). Neuroscience and Biobehavioral Reviews 35(8): 1779-1787, 2011. (131 refs.)

Cannabis is one of the most commonly used illicit drugs, and despite the widely held belief that it is a safe drug, its long-term use has potentially harmful consequences. To date, the research on the impact of its use has largely been epidemiological in nature and has consistently found that cannabis use is associated with schizophrenia outcomes later in life, even after controlling for several confounding factors. While the majority of users can continue their use without adverse effects, it is clear from studies of psychosis that some individuals are more vulnerable to its effects than others. In addiction, evidence from both epidemiological and animal studies indicates that cannabis use during adolescence carries particular risk. Further studies are warranted given the increase in the concentration of the main active ingredient (Delta(9)-tetrahydrocannabinol) in street preparations of cannabis and a decreasing age of first-time exposure to cannabis.

Chambers RA. A nicotine challenge to the self-medication hypothesis in a neurodevelopmental animal model of schizophrenia. Journal of Dual Diagnosis 5(2): 139-148, 2009. (40 refs.)

Nicotine addiction is the leading cause of premature illness and death in the general population. Up to half of all cigarettes are consumed by a minority of the population: persons with schizophrenia and other forms of mental illness. Ironically, despite nicotine dependence being considered a serious and deadly form of addiction in the general population, research on smoking in mental illness is predominantly guided by the idea that smoking has beneficial medication-like treatment effects. This article considers pitfalls of adherence to the self-medication hypothesis as an exclusively held dogma. New evidence from animal modeling work suggests the need to broaden hypothesis-driven research on smoking in mental illness. Adolescent smoking could predispose to mental illness and/or increased nicotine dependence in schizophrenia may represent an involuntary, general addiction vulnerability that has little to do with the 'helpful' psychoactive effects of nicotine or other drugs.

Clayton S; Borzekowski D; Himelhoch S; Dixon L; Potts W; Medoff D. Media and internet ownership and use among mental health outpatients with serious mental illness. American Journal of Drug and Alcohol Abuse 35(5): 364-367, 2009. (12 refs.)

Objective: To determine whether people with serious mental illness (SMI) and substance use disorder (SUD) use the Internet to receive health information. Methods: One hundred people with SMI were surveyed in community mental health clinics. Results: Participants with SUD were significantly less likely to use the Internet compared to those who without SUD (.34 [.12-.95] p = .04). Internet users with SUD were significantly more likely to report accessing sites topically related to substance abuse (p = .01). Conclusion: Few participants with SMI and SUD used the Internet. Attention to educating patients about quality health information on the Internet may be warranted.

Conover CJ; Weaver M; Arno P; Ang A; Ettner SL. Insurance coverage among people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders. Journal of Health Care for the Poor and Underserved 21(3): 1006-1030, 2010. (59 refs.)

HIV triply-diagnosed adults (those with chronic mental illness and substance abuse disorders) must rely heavily on public insurance to cover high annual medical costs (similar to $50,000). This study examines the nature and determinants of insurance coverage (including managed care) for this population, along with annual transitions in coverage. Relative to people living with HIV/AIDS in general, fewer triply-diagnosed adults rely on private coverage (3% vs. 30%), but their rate of being uninsured is only slightly lower (16% vs. 20%). More than one third of such adults below poverty are uninsured a matter of significant policy concern since the annual income of this group is less than 10% of the amount needed to cover their expected medical expenses. Those with the lowest mental health status were disproportionately represented in managed care. While coverage appears relatively stable over time, those with low incomes and moderate mental health status may face barriers in securing Medicaid.

Crowe SF; Barot J; Caldow S; D'Aspromonte J; Dell'Orso J; Di Clemente A et al. The effect of caffeine and stress on auditory hallucinations in a non-clinical sample. Personality and Individual Differences 50(5): 626-630, 2011. (27 refs.)

Both the diathesis-stress model and the continuum theory of schizophrenia attempt to explain the mechanism by which stress may facilitate the expression of the symptoms of schizophrenia in non-clinical samples. Caffeine has also recently been reported to increase proneness to hallucinate. In this study, 92 non-clinical participants were assigned to either a high or a low stress condition and a high or a low caffeine condition on the basis of self-report. After they had been primed, the participants were asked to listen to white noise and to report each time they heard the song "White Christmas" during the white noise. The song was never played. The results indicated that the interaction of stress and caffeine had a significant effect on the reported frequency of hearing "White Christmas". The results demonstrated that high caffeine levels in association with high levels of stressful life events interacted to produce higher levels of "hallucination" in non-clinical participants, indicating that further caution needs to be exercised with the use of this overtly "safe" drug.

de Hert M. Smoking cessation for patients on clozapine. (editorial). Acta Psychiatrica Scandinavica 124(3): 238-238, 2011. (6 refs.)

DeRosse P; Kaplan A; Burdick KE; Lencz T; Malhotra AK. Cannabis use disorders in schizophrenia: Effects on cognition and symptoms. Schizophrenia Research 120(1-3): 95-100, 2010. (48 refs.)

Objective: Despite the controversy surrounding the possible causal link between cannabis use and the onset of schizophrenia (SZ), data seeking to elucidate the effect of cannabis use disorders (CUDs) on the clinical presentation of SZ have produced mixed results. Although several studies have suggested that CUD in patients with SZ may be associated with variation in cognitive function, clinical presentation and course of illness, the effects have been inconsistent. Methods: We retrospectively ascertained a large cohort (N = 455) of SZ patients with either no history of a CUD (CUD-; N=280) or a history of CUD (CUD+; N = 175). The groups were initially compared on key demographic variables including sex, race, age, age at onset of SZ, parental socioeconomic status, premorbid IQ, education level and global assessment of functioning. Covarying for any observed differences in demographic variables, we then compared groups on lifetime measures of psychotic symptoms as well as a brief battery of neurocognitive tests. Results: Compared to the CUD group the CUD+ group demonstrated significantly better performance on measures of processing speed (Trail Making Tests A and B), verbal fluency (animal naming) and verbal learning and memory (California Verbal Learning Test). Moreover, the CUD+ group had better GAF scores than the CUD group. Conclusions: Collectively, these findings suggest that SZ patients with comorbid CUD may represent a higher functioning subgroup of SZ. Future prospective studies are needed to elucidate the nature of this relationship.

Diaz FJ; James D; Botts S; Maw L; Susce MT; de Leon J. Tobacco smoking behaviors in bipolar disorder: A comparison of the general population, schizophrenia, and major depression. Bipolar Disorders 11(2): 154-165, 2009. (47 refs.)

Objectives: This study compared the prevalence of tobacco smoking behaviors in patients with bipolar disorder with normal and psychiatric (schizophrenia and major depression) controls. The main goal was to establish that bipolar patients smoke more than normal controls. Differences with psychiatric controls were explored. Methods: Samples of 424 patients (99 bipolar, 258 schizophrenia and 67 major depression) and 402 volunteer controls were collected in Central Kentucky. Smoking data for Kentucky's general population were available. Odds ratios (ORs) and their 95% confidence intervals (CIs) were used to establish the strength of associations. Logistic regression was used to adjust ORs for confounding variables. Results: Using epidemiological definitions of smoking behaviors and the general population as controls provided bipolar disorder unadjusted ORs of 5.0 (95% CI: 3.3-7.8) for current cigarette smoking, 2.6 (95% CI: 1.7-4.4) for ever cigarette smoking, and 0.13 (95% CI: 0.03-0.24) for smoking cessation. Using a clinical definition and volunteers as controls provided respective bipolar disorder adjusted ORs of 7.3 (95% CI: 4.3-12.4), 4.0 (95% CI: 2.4-6.7), and 0.15 (95% CI: 0.06-0.36). Prevalences of current daily smoking for patients with major depression, bipolar disorder, and schizophrenia were 57%, 66%, and 74%, respectively. Conclusions: Bipolar disorder was associated with significantly higher prevalences of tobacco smoking behaviors compared with the general population or volunteer controls, independently of the definition used. It is possible that smoking behaviors in bipolar disorder may have intermediate prevalences between major depression and schizophrenia, but larger samples or a combination of multiple studies (meta-analysis) will be needed to establish whether this hypothesis is correct.

DiClemente CC; Delahanty JC; Kofeldt MG; Dixon L; Goldberg R; Lucksted A. Stage movement following a 5A's intervention in tobacco dependent individuals with serious mental illness (SMI). Addictive Behaviors 36(3): 261-264, 2011. (20 refs.)

Smoking among individuals with serious mental illness (SMI) creates significant health problems. This study explored stage of change transitions over time among smokers with serious mental illness (SMI) and how dose of a brief intervention and other psychosocial variables were related to stage transitions. Participants were a subsample of 110 patients who participated in a larger controlled trial (Dixon, et al., 2009) examining whether psychiatrists in mental health clinics implementing the "5A's" (Ask, Advise, Assess, Assist, and Arrange) significantly reduced smoking among persons with SMI. Participants were classified into one of the Transtheoretical Model (TTM) Stages of Change for Smoking Cessation as well as classified into groups based upon the pattern of stage status transitions over time (i.e., Regressors, Stable, Inconsistent, Progressors with and without a successful quit). Modest quit rates for this brief intervention were found at one-year (6.4%) and the dose of the intervention was meaningfully related to positive stage transitions. Cessation outcomes from the controlled trial (Dixon,et al., 2009) indicated a small effect on smoking cessation, which is confirmed in this stage transition secondary analysis with a subset of these smokers. However, these results suggest that a brief intervention delivered by psychiatrists in a mental health treatment setting does seem to make an impact on these smokers.

Doran D; Paterson J; Clark C; Srivastava R; Goering PN; Kushniruk AW et al. A pilot study of an electronic interprofessional evidence-based care planning tool for clients with mental health problems and addictions. Worldviews on Evidence-Based Nursing 7(3): 174-184, 2010. (14 refs.)

Background: The health system must develop effective solutions to the growing challenges it faces with respect to individuals who suffer with mental health disorders and addictions. The purpose of this study was to evaluate the usability and potential impact on outcomes of a knowledge translation system aimed at improving client-centered, evidence-based care for hospitalized individuals with schizophrenia. Methodology: A pre-posttest design was used. The e-Volution-TREAT system was implemented on two inpatient units at a large mental health facility. Thirty-seven nurses, allied health workers, and physicians participated from two units. Data collection involved questionnaires, semistructured interviews, and observations. Thirty-eight consenting clients' outcome data were collected from organizational records. Results: Overall, staff participants were very satisfied with the functions of the e-Volution-TREAT system. Barriers to using the system were identified by participants related to the work environment, to understaffing, equipment problems, discomfort with technology, and a focus on short-term rather than long-term goals. There was moderate uptake of guidelines related to social issues, and low uptake of guidelines related to family support and addictions. There were significant improvements in four client outcomes over time, specifically aggressive behavior, depression, withdrawal, and psychosis. Conclusions: In conclusion, users were overall satisfied with the e-Volution-TREAT system, although expressed challenges related to workload that interfered with time to utilize the system. It would be premature to conclude the change in client outcomes was related to the e-Volution-TREAT system without a randomized controlled trial with outcomes compared to a control group. Future research needs to incorporate strategies for modifying the context and engage clinicians who are in a position of influence to model change.

Dulude L; Labelle A; Knott VJ. Acute nicotine alteration of sensory memory impairment in smokers with schizophrenia. Journal of Clinical Psychopharmacology 30(5): 541-548, 2010. (80 refs.)

Context: Patients with schizophrenia have a high rate of cigarette smoking and also exhibit profound deficits in sensory processing, which may in part be ameliorated by the acute actions of smoke-inhaled nicotine. The mismatch negativity (MMN), a preattentive event-related potential index of auditory sensory memory, is diminished in schizophrenia. The MMN is increased in healthy controls with acute nicotine. Objective: To utilize the MMN to compare auditory sensory memory in minimally tobacco-deprived (3 hours) patients and matched tobacco-deprived smoking controls and to assess the effects of acute nicotine on MMN-indexed sensory memory processing in the patients. Design: Event-related potentials were recorded in 2 auditory oddball paradigms, one involving tone frequency changes (frequency MMN) and one involving tone duration changes (duration MMN). Controls were assessed once under nontreatment conditions, and patients were assessed twice under randomized double-blind treatment conditions involving placebo and nicotine (8 mg) gum. Setting: Outpatient mental health center. Patients: Twelve smokers with schizophrenia and twelve control smokers. Results: Compared with the controls, the patients showed reduced frequency-MMN (P < 0.001) and duration-MMN (P < 0.04) amplitudes. In addition to prolonging peak latency in duration MMN (P < 0.01), nicotine, relative to placebo, increased the amplitude of the patients' duration MMN (P G 0.01), but not their frequency MMN, to a level comparable with that seen in the controls. Conclusions: These preliminary findings demonstrate for the first time that acute nicotine can normalize temporal aspects of sensory memory processing in patients with schizophrenia, an effect that may be mediated by activation of alpha 7 nicotinic acetylcholine receptors, the function of which is diminished in schizophrenia. These ameliorating actions of nicotine may have implications for understanding the close relationship between tobacco smoking and schizophrenia and for developing nicotinic pharmacotherapies to alleviate sensory memory impairments in schizophrenia.

Fazel S; Langstrom N; Hjern A; Grann M; Lichtenstein P. Schizophrenia, substance abuse, and violent crime. Journal of the American Medical Association 301(19): 2016-2023, 2009

Context: Persons with schizophrenia are thought to be at increased risk of committing violent crime 4 to 6 times the level of general population individuals without this disorder. However, risk estimates vary substantially across studies, and considerable uncertainty exists as to what mediates this elevated risk. Despite this uncertainty, current guidelines recommend that violence risk assessment should be conducted for all patients with schizophrenia. Objective To determine the risk of violent crime among patients diagnosed as having schizophrenia and the role of substance abuse in mediating this risk. Design, Setting, and Participants: Longitudinal designs were used to link data from nationwide Swedish registers of hospital admissions and criminal convictions in 1973-2006. Risk of violent crime in patients after diagnosis of schizophrenia (n = 8003) was compared with that among general population controls (n = 80 025). Potential confounders (age, sex, income, and marital and immigrant status) and mediators (substance abuse comorbidity) were measured at baseline. To study familial confounding, we also investigated risk of violence among unaffected siblings (n = 8123) of patients with schizophrenia. Information on treatment was not available. Main Outcome Measure: Violent crime (any criminal conviction for homicide, assault, robbery, arson, any sexual offense, illegal threats, or intimidation). Results In patients with schizophrenia, 1054 (13.2%) had at least 1 violent offense compared with 4276 (5.3%) of general population controls (adjusted odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2). The risk was mostly confined to patients with substance abuse comorbidity (of whom 27.6% committed an offense), yielding an increased risk of violent crime among such patients (adjusted OR, 4.4; 95% CI, 3.9-5.0), whereas the risk increase was small in schizophrenia patients without substance abuse comorbidity (8.5% of whom had at least 1 violent offense; adjusted OR, 1.2; 95% CI, 1.1-1.4; P<.001 for interaction). The risk increase among those with substance abuse comorbidity was significantly less pronounced when unaffected siblings were used as controls (28.3% of those with schizophrenia had a violent offense compared with 17.9% of their unaffected siblings; adjusted OR, 1.8; 95% CI, 1.4-2.4; P<.001 for interaction), suggesting significant familial (genetic or early environmental) confounding of the association between schizophrenia and violence. Conclusions: Schizophrenia was associated with an increased risk of violent crime in this longitudinal study. This association was attenuated by adjustment for substance abuse, suggesting a mediating effect. The role of risk assessment, management, and treatment in individuals with comorbidity needs further examination.

Ferron JC; Brunette MF; He XF; Xie HY; McHugo GJ; Drake RE. Course of smoking and quit attempts among clients with co-occurring severe mental illness and substance use disorders. Psychiatric Services 62(4): 353-359, 2011. (51 refs.)

Objective: Approximately three-quarters of people with severe mental illnesses smoke cigarettes, and the rate is even higher among those with co-occurring substance use disorders. This longitudinal study explored patterns of cigarette use and cessation attempts among mental health clients with co-occurring disorders. Methods: Clients participating in a longitudinal study of co-occurring disorders (N=174) were assessed yearly over 11 years for smoking and smoking cessation behaviors, psychiatric symptoms, and other substance use, as well as social, occupational, and other characteristics. Generalized linear mixed-effects models were used to examine smoking cessation outcomes. Results: Eighty-nine percent of participants were current smokers at baseline. Seventy-five percent of participants tried to quit at least once over the 11 years of the study, although none received nicotine replacement therapy or bupropion. Only 17% were not smoking at the 11-year follow-up. The presence of a chronic general medical condition predicted a longer duration of not smoking in the past year. Being male and having a high school education or higher were associated with more attempts to quit smoking, as were higher scores on the activation subscale of the Brief Psychiatric Rating Scale, more social contact with non-substance-using friends, and more daily activities. Conclusions: Although many clients with co-occurring serious mental illness and substance use disorders tried to quit each year, few achieved sustained abstinence and none used evidence-based interventions (nicotine replacement therapy or bupropion). Treatment providers need to administer evidence-based interventions to help people quit successfully.

Ferron JC; Brunette MF; McHugo GJ; Devitt TS; Martin WM; Drake RE. Developing a quit smoking website that is usable by people with severe mental illnesses. Psychiatric Rehabilitation Journal 35(2): 111-116, 2011

Objective: Evidence-based treatments may be delivered in computerized, web-based formats. This strategy can deliver the intervention consistently with minimal treatment provider time and cost. However, standard web sites may not be usable by people with severe mental illnesses who may experience cognitive deficits and low computer experience. This manuscript reports on the iterative development and usability testing of a website designed to educate and motivate adults with severe mental illnesses to engage in smoking cessation activities. Methods: Three phases of semi-structured interviews were performed with participants after they used the program and combined with information from screen-recorded usability data. T-tests compared the differences between uses of the first computer program version and a later version. Results: Iteratively conducted usability tests demonstrated an increased ease of use from the first to the last version of the website through significant improvement in the percentage of unproductive clicking along with fewer questions asked about how to use the program. The improvement in use of the website resulted from changes such as: integrating a mouse tutorial, increasing font sizes, and increasing button sizes. Conclusions and Implications for Practice: The website usability recommendations provide some guidelines for interventionists developing web tools for people who experience serious psychiatric disabilities. In general, insights from the study highlight the need for thoughtful design and usability testing when creating a website for people with severe mental illness.

Foti DJ; Kotov R; Guey LT; Bromet EJ. Cannabis use and the course of schizophrenia: 10-year follow-up after first hospitalitalization. American Journal of Psychiatry 167(8): 987-993, 2010. (40 refs.)

Objective: The authors examined the relationship between cannabis use and the course of illness in schizophrenia over 10 years of follow-up after first psychiatric hospitalization. Method: The authors assessed 229 patient S with a schizophrenia spectrum disorder five times: during the first admission and 6 months, 2 years, 4 years, and 10 years later. Ratings of cannabis use and psychiatric symptoms (psychotic, negative, disorganized, and depressive) were made at each assessment. Results: The lifetime rate of cannabis use was 66.2%, and survival analysis revealed that lifetime use was associated with an earlier onset of psychosis. The rates of current use ranged from 10% to 18% across assessments. Cannabis status was moderately stable, with tetrachoric correlation coefficients between waves ranging from 0.48 to 0.78. Mixed-effects logistic regression revealed that changes in cannabis use were associated with changes in psychotic symptoms over time even after gender, age, socioeconomic status, other drug use, antipsychotic medication use, and other symptoms were controlled for. Structural equation modeling indicated that the association with psychotic symptoms was bidirectional. Conclusions: Cannabis use is associated with an adverse course of psychotic symptoms in schizophrenia, and vice versa, even after taking into account other clinical, substance use, and demographic variables.

Fridberg DJ; Vollmer JM; O'Donnell BF; Skosnik PD. Cannabis users differ from non-users on measures of personality and schizotypy. Psychiatry Research 186(1): 46-52, 2011. (65 refs.)

Accumulating evidence indicates that cannabis use may be a risk factor for schizophrenia (SZ), and chronic cannabis users score higher than non-users on measures of schizotypal personality traits. The purpose of the present study was to investigate the relations between normal personality, schizotypy, and cannabis use. Sixty-two chronic cannabis users and 45 cannabis-naive controls completed a measure of normal personality, the NEO-Five Factor Inventory (NEO-FFI), and two measures of schizotypy, the schizotypal personality questionnaire (SPQ) and perceptual aberration scale (PAS). Substance use was assessed using the SCID I alcohol/drug module and a locally developed drug use questionnaire. On the NEO-FFI, users scored higher than controls on openness, but lower on agreeableness and conscientiousness, and endorsed greater schizotypy on the SPQ and PAS. Higher neuroticism predicted greater schizotypy in both groups, and, higher Extraversion predicted lower negative-syndrome schizotypy among users. Finally, duration of cannabis use was positively correlated with scores on the SPQ and PAS among users, suggesting a relation between overall cannabis use chronicity and schizotypy. These data show that cannabis users differ from non-users on dimensions of normal personality and schizotypy, and provide further evidence that cannabis use is associated with increased levels of psychosis-related personality traits.

Frisher M. The science and politics of cannabis, drugs and schizophrenia - Commentary on: Cannabis causes schizophrenia? So does nicotine (editorial). Addiction Research & Theory 18(6): 609-611, 2010. (11 refs.)

Goldberger C; Dervaux A; Gourion D; Bourdel MC; Loo H; Laqueille X et al. Variable individual sensitivity to cannabis in patients with schizophrenia. International Journal of Neuropsychopharmacology 13(9): 1145-1154, 2010. (54 refs.)

There is now compelling evidence that cannabis consumption might precipitate psychosis onset. The objective of the present study was to assess the role of individual sensitivity to the psychotogenic effect of cannabis in male patients with schizophrenia. The lifetime diagnosis, disease and substance-use history were determined using a standardized interview in 190 patients with schizophrenia. Of patients with lifetime cannabis use (n=121), 44 were characterized as Cannabis-sensitive (CS) patients if the onset of psychotic symptoms occurred within 1 month following the initiation of cannabis consumption, or following a marked rise of cannabis consumption, or marked aggravation of psychotic symptoms each time the subject used cannabis. Age at onset of psychosis was not different in patients with lifetime cannabis use compared to non-users. By contrast, the first psychotic episode occurred 2.6 yr earlier in CS compared to Non-cannabis-sensitive (NCS) patients (p=0.006). Moreover, a specific excess of family history of psychotic disorder was found in CS patients, but not of any other psychiatric disorder, as well as an earlier age at exposure to cannabis (16.7 +/- 2.5 yr, p=0.03). Sensitivity to psychotogenic effects of cannabis in schizophrenia patients could be related to both genetic vulnerability to schizophrenia and the influence of cannabis on brain maturation and could modulate the influence of cannabis on the onset of schizophrenia.

Gonzalez-Maeso J; Sealfon SC. Psychedelics and schizophrenia. Trends in Neurosciences 32(4): 225-232, 2009. (86 refs.)

Research on psychedelics such as lysergic acid diethylamide (LSD) and dissociative drugs such as phencyclidine (PCP) and the symptoms, neurochemical abnormalities and treatment of schizophrenia have converged. The effects of hallucinogenic drugs resemble some of the core symptoms of schizophrenia. Some atypical antipsychotic drugs were identified by their high affinity for serotonin 5-HT2A receptors, which is also the target of LSD-like drugs. Several effects of PCP-like drugs are strongly affected by both 5-HT2A and metabotropic glutamate 2/3 receptor modulation. A serotonin-glutamate receptor complex in cortical pyramidal neurons has been identified that might be the target both of psychedelics and the atypical and glutamate classes of antipsychotic drugs. Recent results on the receptor, signaling and circuit mechanisms underlying the response to psychedelic and antipsychotic drugs might lead to unification of the serotonin and glutamate neurochemical hypotheses of schizophrenia.

Gregg L; Barrowclough C; Haddock G. Development and validation of a scale for assessing reasons for substance use in schizophrenia: The ReSUS scale. Addictive Behaviors 34(10, Special Issue): 830-837, 2009. (31 refs.)

This paper reports on the development of a questionnaire to assess self reported reasons for substance use in schizophrenia: the 'reasons for substance use in schizophrenia' (ReSUS) scale and explores the relationship between reasons for use, psychiatric symptoms and substance use in a sample of 230 people with psychosis. Principal components analysis revealed three subscales: "coping with distressing emotions and symptoms', "social enhancement and intoxication" and "individual enhancement". Predicted associations were partially supported. 'Coping' reasons for use were related to positive symptoms, general symptoms, global functioning, depression and suicide behaviour as well as substance use (quantity of use and problems related to use). 'Individual enhancement' reasons were related to positive symptoms, to global functioning and to negative consequences of substance use. 'Social enhancement and intoxication' reasons were related to negative consequences of use but not to psychopathology. The findings suggest that the ReSUS is a reliable and valid instrument which can be used to explore self reported reasons for substance use and their relationship to psychotic symptoms in people with schizophrenia and other psychotic disorders.

Griffiths M; Kidd SA; Pike S; Chan J. The tobacco addiction recovery program: Initial outcome findings. Advances in Psychiatric Nursing 24(4): 239-246, 2010. (28 refs.)

Tobacco addiction is a major cause of excess mortality among individuals with severe mental illness (SMI). This study examined the impact of a brief group intervention developed for individuals with SMI that integrates evidence-based and recovery-oriented strategies to address tobacco addiction. The intervention was found to significantly decrease tobacco use and dependence and increase participants' sense of self-efficacy with respect to resisting the urge to smoke. These preliminary findings indicate that the Tobacco Addiction Recovery Program intervention is an effective, recovery-oriented intervention for tobacco addiction.

Hall W. Does a lack of specificity rule out a causal relationship between cannabis use and schizophrenia? (editorial). Addiction Research & Theory 18(6): 606-608, 2010. (10 refs.)

In this article, the author discusses a study on the causal relationship between cannabis use and schizophrenia. He stresses that cannabis use cannot be a contributory cause of psychoses because the same type of evidence also exists for a causal relationship between cigarette smoking and psychosis. He emphasizes that the argument that a contributory causal role for cannabis in psychosis is weakened because tobacco smoking satisfies many of the same criteria for casual inference as cannabis use.

Hall W; Degenhardt L. What are the policy implications of the evidence on cannabis use and psychosis? (editorial). Addiction 105(8): 1332-1333, 2010. (14 refs.)

Hermens DF; Lubman DI; Ward PB; Naismith SL; Hickie IB. Amphetamine psychosis: A model for studying the onset and course of psychosis. Medical Journal of Australia 190(4, Supplement): S22-S25, 2009. (33 refs.)

The aetiology of schizophrenia remains complex, although proposed models have identified genetic markers and environmental pathogens as important risk factors. Researchers have found no large-effect or unique genetic elements, and only a small number of putative environmental agents have been identified. Use of amphetamine-type stimulants (ATSs) is an exemplar environmental pathogen, as it is known to trigger schizophrenia-like illness and other psychotic and manic episodes. To date, the ATS model of illness onset has been under-utilised. It has the potential to reveal key neurobiological elements of schizophrenia and related psychoses. The model proposed here has the capacity to inform detection of those at risk of ATS-related psychoses, and therefore help develop early intervention strategies. It is possible that the same approach may be used in young people known to be at risk of schizophrenia and related disorders, by informing models that involve other environmental or genetic risks.

Hides L; Kavanagh DJ; Dawe S; Young RM. The influence of cannabis use expectancies on cannabis use and psychotic symptoms in psychosis. Drug and Alcohol Review 28(3): 250-256, 2009. (43 refs.)

Introduction and Aims. Little is known about motives or expectancies for cannabis use in psychotic populations, despite these cognitive factors being a central focus of the treatment for substance misuse in psychosis. This study examined the relationship between cannabis use expectancies, cannabis use and psychotic symptoms among cannabis using psychotic inpatients. A secondary aim was to determine if there were significant differences in the cannabis use expectancies of psychotic patients with and without Diagnostic and Statistical Manual version IV (DSM-IV) cannabis dependence. Design and Methods. Participants consisted of 101 in-patients with psychosis who had used cannabis more than five times in the past year. Expectancies were assessed using the Cannabis Expectancy Questionnaire (CEQ). The frequency of cannabis use, severity of cannabis dependence, presence of DSM-IV cannabis dependence and severity of psychotic symptoms were also assessed using standardised measures. Results and Conclusions. Results suggested that cannabis use expectancies were associated with cannabis use but not symptom variables. Expectances for cannabis use predicted recent cannabis use and the presence and severity of cannabis dependence. Psychotic patients with DSM-IV cannabis dependence had significantly higher expectancies for negative effects from cannabis use. Prospective research examining the influence of motives and expectancies for cannabis use on cannabis use and psychotic symptoms is required to obtain a greater understanding of substance use in psychosis and assist with the development of innovative treatment interventions.

Jimenez-Castro L; Hare E; Medina R; Raventos H; Nicolini H; Mendoza R et al. Substance use disorder comorbidity with schizophrenia in families of Mexican and Central American Ancestry. Schizophrenia Research 120(1-3): 87-94, 2010. (46 refs.)

Objectives: The aims of this study were to estimate the frequency and course of substances use disorders in Latino patients with schizophrenia and to ascertain risk factors associated with substance use disorders in this population. Method: We studied 518 subjects with schizophrenia recruited for a genetic study from the Southwest United States, Mexico, and Central America (Costa Rica and Guatemala). Subjects were assessed using structured interviews and a best estimate consensus process. Logistic regression, chi(2), t test, Fisher's exact test, and Yates' correction, as appropriate, were performed to assess the sociodemographic variables associated with dual diagnosis. We defined substance use disorder as either alcohol or substance abuse or dependence. Results: Out of 518 patients with schizophrenia, 121 (23.4%) had substance use disorders. Comorbid substance use disorders were associated with male gender, residence in the United States, immigration of Mexican men to the United States, history of depressive syndrome or episode, and being unemployed. The most frequent substance use disorder was alcohol abuse/dependence, followed by marijuana abuse/dependence, and solvent abuse/dependence. Conclusion: This study provides data suggesting that depressive episode or syndrome, unemployment, male gender, and immigration of Mexican men to the United States were factors associated with substance use disorder comorbidity in schizophrenia. Binary logistic regression showed that country of residence was associated with substance use disorder in schizophrenic patients. The percentage of subjects with comorbid substance use disorders was higher in the Latinos living in the United States compared with subjects living in Central America and Mexico.

Jones RM; Lichtenstein P; Grann M; Langstrom N; Fazel S. Alcohol use disorders in schizophrenia: A national cohort study of 12,653 patients. Journal of Clinical Psychiatry 72(6): 775-779, 2011. (40 refs.)

Background: Comorbid alcohol use disorders (AUDs) in schizophrenia are associated with increased morbidity, more inpatient treatment, and violent offending. It is of clinical importance to identify those with schizophrenia who may go on to develop an alcohol use disorder; however, the risk factors are not well understood. The aim of this study was to identify risk factors for the development of an AUD in patients after they had been diagnosed with schizophrenia. Method: We conducted a retrospective case-control study of 12,653 individuals diagnosed with ICD-defined schizophrenia in Sweden in 1973-2004, using data from national registers. We tested the associations between individual factors (marital status, immigrant status, and previous violent offending), sociodemographic factors (income and education), and parental risk factors (AUDs, psychosis, and violent offending) ICD-defined and AUD development using logistic regression modeling. Results: Over a median follow-up of 17.3 years, 7.6% of patients had at least 1 hospital diagnosis of AUD. After adjustment for gender and age at diagnosis in a multivariate regression model, previous violent offending (OR=2.1; 95% CI, 1.8-2.5), low education (OR=1.3; 95% CI, 1.1-1.5), maternal AUD (OR=1.9; 95% CI, 1.4-2.7), and paternal AUD (OR=1.9; 95% CI, 1.5-2.3) remained independently associated with increased risk of patient AUD. Conclusions: AUDs are a common sequela of schizophrenia. Risk factors that could be identified at the time of first presentation include low educational attainment, previous violent offending, and parental history of AUDs and may inform clinical treatment and follow-up of those most at risk.

Kahn RS; Linszen DH; van Os J; Wiersma D; Bruggeman R; Cahn W et al. Evidence that familial liability for psychosis is expressed as differential sensitivity to cannabis an analysis of patient-sibling and sibling-control pairs. Archives of General Psychiatry 68(2): 138-147, 2011. (61 refs.)

Context: Individual differences in cannabis sensitivity may be associated with genetic risk for psychotic disorder. Objectives: To demonstrate and replicate, using 2 conceptually different genetic epidemiological designs, that (familial) liability to psychosis is associated with sensitivity to cannabis. Design, Setting, and Participants: Sibling-control and cross-sibling comparisons using samples of patients with a psychotic disorder (n=1120), their siblings (n=1057), and community controls (n=590) in the Netherlands and Flanders. Main Outcome Measures: Positive and negative schizotypy using the Structured Interview for Schizotypy-Revised (for siblings and controls) and self-reported positive and negative psychotic experiences using the Community Assessment of Psychic Experiences (for siblings and patients). Cannabis use was assessed as current use (by urinalysis) and lifetime frequency of use (by Composite International Diagnostic Interview). Results: In the sibling-control comparison, siblings displayed more than 15 times greater sensitivity to positive schizotypy associated with particularly current cannabis use by urinalysis (adjusted B=0.197, P<.001) than controls (adjusted B=0.013, P=.86) (P interaction=.04) and a similar difference in sensitivity to its effect on negative schizotypy (siblings: adjusted B=0.120, P<.001; controls: B=-0.008, P=.87; P interaction=.03). Similarly, siblings exposed to cannabis resembled their patient relative nearly 10 times more closely in the positive psychotic dimension of the Community Assessment of Psychic Experiences (adjusted B=0.278, P<.001) compared with nonexposed siblings (adjusted B=0.025, P=.12) (P interaction<.001). No significant effect was apparent for the Community Assessment of Psychic Experiences negative domain, although the association was directionally similar (2 times more resemblance; P interaction=.17). Crosssibling, cross-trait analyses suggested that the mechanism underlying these findings was moderation (familial risk increasing sensitivity to cannabis) rather than mediation (familial risk increasing use of cannabis). Conclusions: Genetic risk for psychotic disorder may be expressed in part as sensitivity to the psychotomimetic effect of cannabis. Cannabis use may synergistically combine with preexisting psychosis liability to cause positive and negative symptoms of psychosis.

Kim SH; Han DH; Joo SY; Min KJ. The effect of dopamine partial agonists on the nicotine dependency in patients with schizophrenia. Human Psychopharmacology: Clinical and Experimental 25(2): 187-190, 2010. (14 refs.)

Objective: We compared the effects of haloperidol and three atypical antipsychotics (risperidone, olanzapine, and aripiprazole) on nicotine dependence in schizophrenic patients. Methods: One hundred and thirty nine schizophrenic patients, who began using antipsychotic medication, were assessed for severity of nicotine dependence and for cigarette craving at baseline and following 8 weeks of treatment using the Fagerstrom Tolerance Questionnaire (FTQ) and a Likert-style, seven point, visual-analogue rating scale. Results: Nicotine dependence increased in the haloperidol group, but not in atypical antipsychotics groups. Patients treated with aripiprazole showed a reduction both in nicotine dependence and cigarette craving. Conclusions: The effects of aripiprazole, a partial agonist of the dopamine D2 receptor, may reduce the severity of nicotine dependence in schizophrenic patients.

Kisely S. Excess mortality from chronic physical disease in psychiatric patients: The forgotten problem. Canadian Journal of Psychiatry 55(12): 749-751, 2010. (26 refs.)

In the case of schizophrenia, the risk is considerably greater. Patients with major mental illnesses, such as schizophrenia, and major depressive, bipolar, and delusional disorders, can die up to 25 years earlier than the general population. Contrary to common perception, it is not suicide that accounts for most of these deaths among people with mental illness, but common diseases such as heart disease, cancer, and chronic lung disease. Excess mortality from these diseases is 10 times that of deliberate self-harm yet receives little attention when compared with suicide prevention. [...] psychiatrists need to be aware of the potential risks of psychotropic medications when selecting therapy, and that these are greatest in the initial years of treatment. Patient-based explanations could include lower compliance with treatment, problems with communication, or difficulties in giving informed consent. Up to 80% of patients with chronic schizophrenia smoke. Nevertheless, clinicians may be missing opportunities to help psychiatric patients quit, even though there are effective treatments available. In a survey of patients admitted to a smoke-free psychiatric unit, nicotine replacement therapy was only prescribed in just over one-half of the smokers, even though they showed evidence of nicotine withdrawal. Less than 1% were encouraged to stop smoking, referred for a formal cessation program, or provided with nicotine replacement therapy on discharge. Among outpatients, psychiatrists are less likely to offer smoking cessation counselling than family physicians. Psychiatric patients receive cessation counselling in only 12% of visits to a psychiatrist, compared with 38% of primary care contacts. It is noted that resources are available, such as Toolkits, produced by the Canadian Collaborative Mental Health Initiative for use in primary care, emphasizing the need to monitor physical health, especially in people with severe mental illness.

Koskinen J; Lohonen J; Koponen H; Isohanni M; Miettunen J. Rate of cannabis use disorders in clinical samples of patients with schizophrenia: A meta-analysis. Schizophrenia Bulletin 36(6): 1115-1130, 2010. (59 refs.)

Objective: Our aim was to review recent studies and estimate the rate of cannabis use disorders (CUDs) in schizophrenia, as well as to examine the factors affecting this rate. Methods: We conducted an electronic search of 3 literature databases and a manual search of articles from 1996 to 2008. The key words used were "schizophreni*," "psychos*s," "psychotic," "cannabis abuse," "cannabis dependence," "cannabis use disorder," "substance use disorder," "substance abuse," "substance dependence," and "dual diagnosis." Articles that reported diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases were included. Regression analysis was used to examine how estimated rates of CUDs are affected by various study characteristics such as the classification system, inpatient vs outpatient status, study location, proportion of males, age of the sample, or duration of illness. Results: Thirty-five studies met our search criteria. The median current rate of CUDs was 16.0% (interquartile range [IQR] = 8.6-28.6, 10 studies), and the median lifetime rate was 27.1% (IQR = 12.2-38.5, 28 studies). The median rate of CUDs was markedly higher in first-episode vs long-term patients (current 28.6%/22.0%, lifetime 44.4%/12.2%, respectively) and in studies where more than two-thirds of the participants were males than in the other studies (33.8%/13.2%). CUDs were also more common in younger samples than in the others (current 38.5%/16.0%, lifetime 45.0%/17.9%). Conclusions: Approximately every fourth schizophrenia patient in our sample of studies had a diagnosis of CUDs. CUDs were especially common in younger and first-episode patient samples as well as in samples with a high proportion of males.

Kuepper R; Morrison PD; van Os J; Murray RM; Kenis G; Henquet C. Does dopamine mediate the psychosis-inducing effects of cannabis? A review and integration of findings across disciplines. (review). Schizophrenia Research 121(1-3): 107-117, 2010. (163 refs.)

General population epidemiological studies have consistently found that cannabis use increases the risk of developing psychotic disorders in a dose-dependent manner. While the epidemiological signal between cannabis and psychosis has gained considerable attention, the biological mechanism whereby cannabis increases risk for psychosis remains poorly understood. Animal research suggests that delta-9-tetrahydrocannabinol (THC, the main psychoactive component of cannabis) increases dopamine levels in several regions of the brain, including striatal and prefrontal areas. Since dopamine is hypothesized to represent a crucial common final pathway between brain biology and actual experience of psychosis, a focus on dopamine may initially be productive in the examination of the psychotomimetic effects of cannabis. Therefore, this review examines the evidence concerning the interactions between THC, endocannabinoids and dopamine in the cortical as well as subcortical regions implicated in psychosis, and considers possible mechanisms whereby cannabis-induced dopamine dysregulation may give rise to delusions and hallucinations. It is concluded that further study of the mechanisms underlying the link between cannabis and psychosis may be conducted productively from the perspective of progressive developmental sensitization, resulting from gene-environment interactions.

Lagoni L; Crawford E; Huss MT. An examination of the self-medication hypothesis via treatment completion. Addiction Research & Theory 19(5): 416-426, 2011. (24 refs.)

A long-held clinical belief is that many of the mentally ill seek relief from their symptoms through the use of alcohol and other illicit substances. The notion of self-medication became formalized in the literature via the self-medication hypothesis (SMH) of addictive disorders (Khantzian, 1985). This study attempted to examine the role of treatment completion for the SMH by examining 696 participants in a dual diagnosis program. Logistic regressions were conducted using mental health demographic variables on drug of choice. In addition, this study extended previous research by employing a path analytic process and examining the complex relationships between these variables in the context of treatment completion. Results indicated little support for the presence of self-medication in this sample.

Lawrence D; Mitrou F; Zubrick SR. Smoking and mental illness: Results from population surveys in Australia and the United States. BMC Public Health 9(article 285), 2009. (84 refs.)

Background: Smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys. Methods: Survey data from the US National Comorbidity Survey-Replication conducted in 2001 2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated. Results: In both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder -31.7% in the US (95% CI: 29.5%-33.8%) and 32.4% in Australia (95% CI: 29.5%-35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day. Conclusion: Mental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

Lee S; Wong YLI; Rothbard AB. Factors associated with departure from supported independent living: Programs for persons with serious mental illness. Psychiatric Services 60(3): 367-373, 2009. (44 refs.)

Objective: Supported housing is a viable model that offers independence and opportunity for community integration. However, previous studies have shown that not all residents can sustain long-term tenancy. This study examined the extent to which personal and housing characteristics predicted positive and negative departures from independent housing programs that provided support services to persons with serious mental illness. Methods: The sample consisted of 237 persons participating in a supported independent living program in Philadelphia. Cox proportional hazards models were used to estimate the effects of personal and housing characteristics on the probability of positive departure (to an arrangement with more autonomy) and negative departure (to an arrangement with more supervision or to homelessness). Results: Most participants (69%) maintained continuous residence in the program for the study period, 14% experienced a positive departure, and 17% a negative departure. A self-reported past substance abuse problem increased the probability of a negative departure, and a more supportive relationship with program staff decreased the probability. A higher income increased the probability of a positive departure, whereas a higher level of social distress in the neighborhood decreased the probability. Conclusions: The findings suggest that long-term housing tenure was not uncommon among supported independent living residents, but some were not able to maintain independent living and were discharged to shelters, institutions, or residential settings with more supervision. Predictors of positive and negative departure identified in this study may help service providers design services to meet the various needs of persons with serious mental illness for stable independent living.

Lin SC; Chen CC; Chen YH; Chung KS; Lin CH. Benzodiazepine prescription among patients with severe mental illness and co-occurring alcohol abuse/dependence in Taiwan. Human Psychopharmacology: Clinical and Experimental 26(3): 201-207, 2011. (40 refs.)

Objective. Because benzodiazepines (BZDs) may be abused, prescribing them is debatable. The purpose of this study was to investigate the prescription of BZDs to explore the current status of BZD use at discharge and at 4 months after discharge. Methods. From 1 January 2006 to 31 December 2006, prescribed doses for BZDs at discharge and at 4 months after discharge were recorded for all discharged inpatients with schizophrenia, bipolar I disorder, and major depressive disorder. Two-way analysis of variance was used to analyze the effects of severe mental illness and co-occurring alcohol abuse/dependence on BZD doses at discharge and at 4 months after discharge. Results. Patients with severe mental illness prescribed with significantly higher rates and higher doses of BZDs at discharge and at 4 months after discharge are more likely to have major depressive disorder and to have co-occurring alcohol abuse/dependence problems. No significant interactions were found between severe mental illness and co-occurring alcohol abuse/dependence. Conclusions. These findings suggest that caution should be applied in prescribing BZDs to patients with severe mental illness, particularly those with major depressive disorder and co-occurring alcohol abuse/dependence. Future studies require being conducted in many different mental health-care systems in Taiwan to generalize the findings.

Lincoln AK; Plachta-Elliott S; Espejo D. Coming in: An examination of people with co-occurring substance use and serious mental illness exiting chronic homelessness. American Journal of Orthopsychiatry 79(2): 236-243, 2009. (19 refs.)

Despite national efforts, the number of people who are chronically homeless in our cities remains high. People with serious mental illness and substance abuse problems continue to represent the majority of those experiencing long-term homelessness. Traditional shelters have difficulty engaging and addressing the needs of this group; however, there are an increasing number of alternative models, including the Safe Haven shelter program, developed to better meet their needs. In this article, the authors examine responses from 28 qualitative interviews conducted with 16 residents of a Safe Haven shelter serving chronically homeless people, at 3 and 9 months after entry. All had a severe mental illness and were actively substance abusing. The importance of a model that respects personhood, a place that feels like home, and challenges faced by residents as they "come in" are emphasized.

Lineberry TW; Allen JD; Nash J; Galardy CW. Population-based prevalence of smoking in psychiatric inpatients: A focus on acute suicide risk and major diagnostic groups. Comprehensive Psychiatry 50(6): 526-532, 2009. (55 refs.)

Objective: The aim of the study was to define the extent of current and lifetime smoking by diagnostic groups and suicide risk as reason for admission in a geographically defined psychiatric inpatient cohort. Design: The study used a population-based retrospective chart review. Methods: Smoking status and discharge diagnoses for Olmsted County, Minnesota, inpatients aged 18 to 65 admitted for psychiatric hospitalization in 2004 and 2005 were abstracted from the electronic medical record. Diagnostic groups were compared to each other using chi(2) tests and Fisher exact test to analyze smoking status within the inpatient sample with significance defined as P <= .05. Results: Eighty percent (80.41) of our sample of 776 patients was hospitalized due to acute suicide risk. Discharge diagnostic group composition included affective disorders (80.3%), substance abuse disorders (36.1%), anxiety disorders (19%), psychotic disorders (16.4%), and personality disorders (10.3%). Of the sample, 72.2% had at least one comorbid disorder. Of the 776 patients, 356 (45.9%) were current smokers. Substance abuse and psychotic disorder diagnoses were significantly correlated with current smoking status (<.0001, .02) with 77.1% and 55.9%, respectively, being current snickers compared to other psychiatric inpatient groups. All diagnostic groups smoked at higher rates and had less success stopping than the US general population. Conclusion: Our findings clearly demonstrate stratification of current smoking and quit rates in psychiatric inpatient diagnostic groups vs the US general population and Minnesota. Further research into the association between suicide risk, smoking, and mortality in the seriously mentally ill is necessary. Recognizing and addressing smoking in psychiatric patients in both hospital and outpatient settings is critical to addressing survival differences compared to the general population.

Ma XH; Li CX; Meng HQ; Du LA; Wang QA; Wang YC et al. Premorbid tobacco smoking is associated with later age at onset in schizophrenia. Psychiatry Research 178(3): 461-466, 2010. (65 refs.)

Rates of cigarette smoking in individuals with schizophrenia well exceed those in the general population and in other mental illnesses. In the present study, we examined the relationship between smoking status, clinical characteristics and cognitive functions in 230 male Chinese schizophrenia patients. They were interviewed by experienced psychiatrists using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (SCID-P). Clinical symptoms were rated using the Positive and Negative Syndrome Scale (PANSS), and the Revised Tolerance Questionnaire (RTQ) used to evaluate the severity of nicotine dependence. Nine neuropsychological tests were used to assess cognitive function. We found that never-smokers had a younger age at examination and earlier onset and longer duration of illness than smokers and ex-smokers. The age of initiation of regular smoking in patients was significantly earlier than their age of illness onset. We found that longer duration of illness was significantly associated with higher RTQ scores. Ex-smokers with schizophrenia performed significantly more poorly on the Stroop C test than smokers. The results imply that smoking may affect cognitive function and illness onset time in patients with schizophrenia.

Macleod J; Hickman M. How ideology shapes the evidence and the policy: What do we know about cannabis use and what should we do? Addiction 105(8): 1326-1330, 2010. (41 refs.)

In the United Kingdom, as in many places, cannabis use is considered substantially within a criminal justice rather than a public health paradigm with prevention policy embodied in the Misuse of Drugs Act. In 2002 the maximum custodial sentence tariff for cannabis possession under the Act was reduced from 5 to 2 years. Vigorous and vociferous public debate followed this decision, centred principally on the question of whether cannabis use caused schizophrenia. It was suggested that new and compelling evidence supporting this hypothesis had emerged since the re-classification decision was made, meaning that the decision should be reconsidered. The re-classification decision was reversed in 2008. We consider whether the strength of evidence on the psychological harms of cannabis has changed substantially and discuss the factors that may have influenced recent public discourse and policy decisions. We also consider evidence for other harms of cannabis use and public health implications of preventing cannabis use. We conclude that the strongest evidence of a possible causal relation between cannabis use and schizophrenia emerged more than 20 years ago and that the strength of more recent evidence may have been overstated -- for a number of possible reasons. We also conclude that cannabis use is almost certainly harmful, mainly because of its intimate relation to tobacco use. The most rational policy on cannabis from a public health perspective would seem to be one able to achieve the benefit of reduced use in the population while minimizing social and other costs of the policy itself. Prohibition, whatever the sentence tariff associated with it, seems unlikely to fulfil these criteria.

McClernon FJ. Neuroimaging of nicotine dependence: Key findings and application to the study of smoking-mental illness co-morbidity. Journal of Dual Diagnosis 5(2): 168-178, 2009. (44 refs.)

Modern neuroimaging techniques offer the opportunity to noninvasively study neuroanatomical and neurofunctional correlates of nicotine dependence and its treatment. In the present review, the most widely used neuroimaging techniques-magnetic resonance imaging (MRI), positron emission tomography, and functional MRI-are briefly described and their strengths and limitations discussed. The use of these techniques has resulted in new insights into the neuropharmacology of tobacco addiction. Studies comparing smokers and nonsmokers have shown that smokers have less grey matter density in frontal brain regions and greater concentrations of nicotinic receptors. Research on the effects of smoking a cigarette confirms that smoking leads to the release of dopamine in brain reward areas and to nicotinic receptor binding. Studies of smoking abstinence have identified functional brain correlates of increased reactivity to smoking-related cues, and worsening of concentration. To date, neuroimaging studies of nicotine dependence among individuals with mental illness have focused almost exclusively on schizophrenia. A conceptual/methodological framework for studying dual diagnosis using neuroimaging measures is provided, with the aim of spurring additional research in this area.

McDonell MG; Angelo F; Sugar A; Rainey C; Srebnik D; Roll J et al. A pilot study of the accuracy of onsite immunoassay urinalysis of illicit drug use in seriously mentally ill outpatients. American Journal of Drug and Alcohol Abuse 37(2): 137-140, 2011. (12 refs.)

Objectives: This pilot study investigated the accuracy of onsite immunoassay urinalysis of illicit drug use in 42 outpatients with co-occurring substance use disorders and serious mental illness. Methods: Up to 40 urine samples were submitted by each participant as part of a larger study investigating the efficacy of contingency management in persons with co-occurring disorders. Each sample was analyzed for the presence of amphetamine, methamphetamine, cocaine, marijuana, and opiates or their metabolites using onsite qualitative immunoassays. One onsite urinalysis was randomly selected from each participant for confirmatory gas chromatography--mass spectrometry (GC--MS) analyses. Results: Agreement between immunoassay and GC--MS was calculated. Agreement was high, with 98%% agreement for amphetamine, methamphetamine, opiate, and marijuana. Agreement for cocaine was 93%. Conclusions: Results of this pilot study support the use of onsite immunoassay screening cups as an assessment and outcome measure in adults with serious mental illness. Scientific significance: Data suggest that onsite urinalysis screenings may be a helpful assessment tool for measuring clinical and research outcomes.

Mineur YS; Picciotto MRMcRae-Clark AL; Verduin ML; Tolliver BK; Carter RE; Wahlquist AE; Brady KT et al. An open-label trial of aripiprazole treatment in dual diagnosis individuals: Safety and efficacy. Journal of Dual Diagnosis 5(1): 83-96, 2009. (42 refs.)

This open-label study evaluated the safety and efficacy of aripiprazole in the treatment of 20 patients with co-morbid schizophrenia, schizoaffective disorder, or bipolar disorder and alcohol, cocaine, and/or marijuana use disorders. Primary outcomes were substance use, measured by the Timeline Followback, and score on the Clinical Global Impression scale for psychiatric and substance use symptoms. The data suggest that aripiprazole may reduce substance use and improve psychiatric symptoms in patients with co-morbid disorders; however, limitations are noted. Subsequent randomized studies are needed to further explore these findings.

Morrison KN; Naegle MA. An evidence-based protocol for smoking cessation for persons with psychotic disorders. Journal of Addictions Nursing 21(2-3): 79-86, 2010. (26 refs.)

Consequences of the use of tobacco products claim the lives of 443,000 Americans and 5.4 million persons worldwide every year. Persons with diagnosed psychiatric illnesses, including addiction, have the highest prevalence of smoking of any population, and smoke more intensely and heavily than others. In preparation for developing a step-wide protocol for a nursing intervention, recent literature on smoking cessation with smokers and those with psychiatric diagnoses was searched. A total of 16 related or specific studies and reviews were identified and critiqued, seeking support for interventions specific to the needs and attributes of this population. Few studies either included or focused on the smoking cessation with those having diagnoses of addiction and/or other psychiatric disorders, although study populations may have included such individuals. The results of research critiques suggest that standard approaches to smoking cessation have comparable success with the general population and persons with psychiatric disorders. The need to tailor interventions to achieve continued smoking cessation, however, remains an important need. The protocol steps are supported by the evidence drawn from the research literature and best practice guidelines.

Mueser KT; Glynn SM; Cather C; Zarate R; Fox L; Feldman J et al. Family intervention for co-occurring substance use and severe psychiatric disorders: Participant characteristics and correlates of initial engagement and more extended exposure in a randomized controlled trial. Addictive Behaviors 34(10, Special Issue): 867-877, 2009. (62 refs.)

Clients with severe mental illness and substance use disorder (i.e., dual disorders) frequently have contact with family members, who may provide valuable emotional and material support, but have limited skills and knowledge to promote recovery. Furthermore, high levels of family conflict and stress are related to higher rates of relapse. The present study was a two-site randomized controlled trial comparing a comprehensive, behaviorally-based family intervention for dual disorders program (FIDD) to a shorter-term family psychoeducational program (FPE). The modal family was a single male son in his early 30s diagnosed with both alcohol and drug problems and a schizophrenia-spectrum disorder participating with his middle-aged mother, with whom he lived. Initial engagement rates following consent to participate in the study and the family intervention programs were moderately high for both programs (88% and 84%, respectively), but rates of longer term retention and exposure to the core elements of each treatment model were lower (61% and 55%, respectively). Characteristics of the relatives were the strongest predictors of successful initial engagement in the family programs with the most important predictor being relatives who reported higher levels of benefit related to the relationship with the client. Subsequent successful exposure to the family treatment models was more strongly associated with client factors, including less severity of drug abuse and male client gender. The results suggest that attention to issues of motivating relatives to participate in family intervention, and more focused efforts to address the disruptive effects of drug abuse on the family could improve rates of engagement and retention in family programs for dual disorders.

North CS. A tale of two studies of two disasters: Comparing psychosocial responses to disaster among Oklahoma City bombing survivors and Hurricane Katrina evacuees. Rehabilitation Psychology 55(3): 241-246, 2010. (34 refs.)

An accumulation of disaster mental health research literature in the last few decades has contributed knowledge to direct disaster mental health interventions. However, no single set of principles can necessarily outline all anticipated mental health needs to be encountered in a particular disaster. Methods: To illustrate how different disaster scenarios may yield a divergence of mental health needs, this article compares mental health findings from two distinctly different studies of two very different populations affected by two very different disasters: directly exposed survivors the Oklahoma City bombing and sheltered evacuees from Hurricane Katrina. Results: Research on the two disasters reviewed illustrates many facets and complexities of postdisaster mental health needs in different populations in different settings after different types of disasters. The major findings of the Oklahoma City bombing study related to posttraumatic stress disorder and the main findings of the Hurricane Katrina study involved need for treatment of preexisting chronic mental health and substance abuse problems. Conclusion: The disaster studies in this review diverged in type of disaster, affected populations, setting, and timing of the study, and these studies yielded a divergence of findings. One disaster mental health model clearly cannot adequately describe all postdisaster scenarios.

O'Hare T; Sherrer M. Drinking motives as mediators between PTSD symptom severity and alcohol consumption in persons with severe mental illnesses. Addictive Behaviors 36(5): 465-469, 2011. (52 refs.)

Research has consistently shown that drinking to alleviate negative emotional states predicts alcohol use and relapse among clients with co-occurring disorders including depressive and posttraumatic stress disorders. However, studies examining the mediating role of drinking motives in persons with severe mental illness (SMI) are few. The current survey of 116 community mental health clients (51.7% men; 47.4% women) diagnosed with either a schizophrenia spectrum disorder (41, 35.3%) or major mood disorder (75, 64.7%) tested the hypothesis that convivial drinking and drinking to cope with negative emotions would mediate posttraumatic stress symptoms (PSS-I) and alcohol consumption (QF). A series of path models revealed that convivial drinking fully mediated hyper-arousal symptoms and alcohol consumption, and negative coping fully mediated total posttraumatic stress symptoms, avoidance and hyper-arousal symptoms and alcohol consumption. The results support an emotional distress reduction model of alcohol use in people with severe mental illness, and highlight the need to assess specific drinking motives and target them in cognitive-behavioral treatment approaches. The cross sectional design employed limits cause-effect inferences regarding mediation, and highlights the need for longitudinal designs to sort out causal pathways among symptoms, drinking motives and alcohol consumption in clients with SMI.

Okoli CTC; Johnson JL; Malchy L. Correlates of secondhand tobacco smoke exposure among persons with severe and persistent mental illness (SPMI): Accessing community mental health services. Community Mental Health Journal 45(3): 188-198, 2009. (61 refs.)

To examine the correlates of secondhand tobacco smoke (SHS) exposure in a sample of individuals with severe and persistent mental illness (SPMI) accessing community mental health services. Cross-sectional data were collected from a voluntary sample of 788 individuals with SPMI. Nonsmokers were more likely to be exposed on the street or at a bus stop, in a park or public place; whereas smokers were more likely to report SHS exposure where they lived and at their friend's homes. In a multivariate model, only number of acquaintances who smoked and the number of sources of SHS exposure remained significantly associated with perceived frequency of SHS exposure when accounting for other correlates. There is a need for the enactment and enforcement of policies to curtail SHS exposure in outdoor, public, settings. Future research will be necessary to better understand the extent and impact of SHS exposure in this population.

Okoli CTC; Khara M; Torchalla I; Ensom MHH; Oliffe JL; Bottorff JL et al. Sex differences in smoking cessation outcomes of a tailored program for individuals with substance use disorders and mental illness. Addictive Behaviors 36(5): 523-526, 2011. (28 refs.)

Tobacco use is highly prevalent among individuals with a history of substance use disorders (SUD) and/or mental illness (MI). Despite evidence of differences in smoking cessation (SC) outcomes between women and men, few studies have formally evaluated sex differences among SUD and/or MI populations. For 258 participants (62% male, mean age = 48.6 years) with an SUD and/or MI enrolled in a tobacco dependence clinic (TDC) program, we examined SC outcomes and compared men's and women's predictors of end-of-treatment abstinence. Individuals with an MI, social support for quitting, and a greater number of visits to the TDC program were more likely to be female; whereas males were characterized by having an SUD, older age, smoking a greater number of cigarettes per day, and having higher confidence in quitting smoking. In the intent-to-treat analysis, end-of-treatment smoking cessation was 32.2% (females = 35.4% vs males = 30.2, chi(2) = 0.74, df = 1, p = .390). Among females, baseline expired carbon monoxide (CO) level and a greater number of visits to the program were significantly predictive of SC: among males, having a history of alcohol, heroin and other opioids, and marijuana use were predictive of unsuccessful SC, whereas baseline expired CO level and a greater number of visits to the program were predictive of SC. These factors may be important in the design of enhanced tailored treatments and development of future SC programs for individuals with SUD and MI.

Ongur D; Lin L; Cohen BM. Clinical characteristics influencing age at onset in psychotic disorders. Comprehensive Psychiatry 50(1): 13-19, 2009. (43 refs.)

Background: Age at onset of psychosis may carry clinical significance across psychotic disorders and appears to be associated with specific genetic abnormalities. Methods: We used the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to examine clinical characteristics contributing to age at onset variability in patients with schizophrenia (n = 80), schizoaffective disorder (n = 61), and bipolar disorder with psychotic features (n = 92). Results: Age at onset did not differ across DSM-IV diagnostic groups. Multiple regression analyses revealed that comorbid lifetime cannabis, but not alcohol, abuse/dependence was associated with a statistically significant 3 years earlier age at onset of psychosis. Patients developed cannabis abuse/dependence an additional 3 years before psychosis. Patients with comorbid lifetime panic disorder also had a 4-year earlier age at onset of psychosis. The effects of panic disorder and cannabis abuse/dependence were independent of one another. Conclusions: Early onset of psychosis, regardless of the specific DSM-IV diagnosis, is characterized by differential clinical features, notably a history of lifetime cannabis abuse/dependence. Panic disorder comorbidity is also associated with earlier age at onset of psychosis. Our findings indicate that examination of clinical and biological characteristics of patients with psychosis regardless of DSM-TV diagnosis can uncover relevant information.

Peters BD; de Haan L; Vlieger EJ; Majoie CB; den Heeten GJ; Linszen DH. Recent-onset schizophrenia and adolescent cannabis use: MRI evidence for structural hyperconnectivity? Psychopharmacology Bulletin 42(2): 75-88, 2009. (65 refs.)

There is growing evidence that brain white matter abnormalities are implicated in the pathophysiology of schizophrenia. Cannabis use is an independent risk factor for schizophrenia. We tested the hypothesis that cannabis use during early adolescence is associated with white matter abnormalities in schizophrenia patients. Thirty-five male recent-onset schizophrenia patients, with and without a history of cannabis use before age 17, and twenty-one matched healthy comparison men without illicit drug use were assessed with diffusion tensor imaging (DTI). White matter regions of interest were examined in co-registered DTI images. Compared to controls, patients with cannabis use before age 17 showed increased directional coherence in the bilateral uncinate fasciculus, anterior internal capsule and frontal white matter. These abnormalities were absent in patients without cannabis use before age 17. The abnormalities were not related to lifetime doses of cannabis or other illicit drugs. We could not exclude confounding effects of other illicit drugs. Recent-onset schizophrenia patients with start of cannabis use during early adolescence use may represent a subgroup of schizophrenia patients with increased white matter directional coherence, which may reflect structural hyperconnectivity. This is in contrast with most DTI studies in schizophrenia, which have produced evidence for hypoconnectivity. Further studies are necessary to assess the effect of adolescent cannabis and other illicit drug use on brain white matter in schizophrenia.

Rabin RA; Zakzanis KK; George TP. The effects of cannabis use on neurocognition in schizophrenia: A meta-analysis. Schizophrenia Research 128(1-3): 111-116, 2011. (47 refs.)

Patients with schizophrenia frequently report cannabis use, yet its effects on neurocognitive functioning in this population are still unclear. This meta-analysis was conducted to determine the magnitude of effect of cannabis consumption on cognition in schizophrenia without the confounding effects of other co-morbid substance use disorders. Eight studies met inclusion criteria yielding a total sample of 942. Three hundred and fifty six of these participants were cannabis users with schizophrenia, and 586 were patients with no cannabis use. Neuropsychological tests were grouped into seven domains (general cognitive ability and intelligence; selective, sustained and divided attention; executive abilities; working memory and learning; retrieval and recognition; receptive and expressive language abilities and visuo-spatial and construction abilities). Effect sizes were computed for each cognitive domain between cannabis-using patients and patients with no history of cannabis use. Effect size differences in cognitive performance in the schizophrenia group as a function of cannabis use were in the small to medium range, denoting superior performance in cannabis-using patients. Explanations for these findings are discussed and suggestions for future research in this area are recommended.

Rodriguez-Jimenez R; Bagney A; Martinez-Gras I; Ponce G; Sanchez-Morla EM; Aragues M et al. Executive function in schizophrenia: Influence of substance use disorder history. Schizophrenia Research 118(1-3): 34-40, 2010. (97 refs.)

Cognitive function in schizophrenia has been associated with different sociodemographic and clinical variables. Substance use disorder (SUD) history has also been associated with cognition in schizophrenia; however, contradictory results have been found regarding its influence on cognitive function. Our aim was to study the relationship between executive function and a) age, b) duration of illness, c) number of psychotic episodes, d) positive symptoms, and e) negative symptoms, in a sample of schizophrenic patients, and secondly to study whether these relationships persisted after stratification of the sample according to the presence or absence of SUD history. A final sample of 203 schizophrenic patients were evaluated for psychotic symptoms using the PANSS, and assessed using a neuropsychological battery to calculate a composite executive function score. Linear regression analyses were performed, with this executive score as the dependent variable, and age, duration of illness, number of psychotic episodes, positive PANSS score and negative PANSS score as independent variables. For the total sample, the regression model showed three variables to be significant predictors of the executive score: age (p = 0.004), number of episodes (p = 0.027), and PANSS negative score (p = 0.003). However, once the sample was stratified, the regression model showed age (p = 0.011) and number of episodes (p = 0.011) to be predictor variables for the executive score in the group of schizophrenic patients with SUD history, while age (p = 0.028) and PANSS negative score (p = 0.006) were predictors in the group of schizophrenic patients without such history. These findings highlight the importance of considering SUD history in studies of cognitive function in schizophrenia.

Room R; Rehm J. Commentary on Hickman et al. (2009): The place of risk in drug policies. (editorial). Addiction 104(11): 1862-1863, 2009. (10 refs.)

This editorial address the issues raised by Hickman that consider the following question: If marijuana use is related to schizophrenia, the number of individuals using marijuana would would need to be reduced by how many persons, in order to prevent one case of schizophrenia or psychosis.

Schladweiler K; Alexandre PK; Steinwachs DM. Factors associated with substance use problem among Maryland Medicaid enrollees affected by serious mental illness. Addictive Behaviors 34(9): 757-763, 2009. (49 refs.)

The objective of this study was to identify long-term factors associated with substance use problem among individuals affected by severe mental illness. Prospective data come from the 1994, 1998, and 2000 waves of the Maryland Mental Health Outcomes Survey conducted among a sub-cohort of adult Medicaid recipients affected by serious mental illness. We estimated factors associated with alcohol and drug problem, as well as a hierarchy of substance use problem severity constructed from the alcohol and drug problem outcomes. Drug problem was the strongest factor associated with alcohol problem, and vice versa. Conceptualizing alcohol and drug problem separately, and as a hierarchy of severity, revealed distinct profiles of significant factors. Further research is warranted to explore the utility of modeling substance use problem in terms of a hierarchy of severity.

Scholes KE; Martin-Iverson MT. Cannabis use and neuropsychological performance in healthy individuals and patients with schizophrenia. Psychological Medicine 40(10): 1635-1646, 2010. (81 refs.)

Background. The effects of cannabis use on neuropsychological indices that show characteristic disturbances in schizophrenia are unclear. The effect of cannabis use on these cognitive functions is of particular interest given the hypothesized association between cannabis use and schizophrenia. Therefore, this study aimed to examine the effects of cannabis use on attentional control, working memory and executive functioning, in both healthy individuals and patients with schizophrenia. Method. Neuropsychological performance was assessed in 36 cannabis users who were otherwise healthy, 35 healthy non-users, 22 cannabis-using patients with schizophrenia, and 49 non-using patients with schizophrenia. Participants were administered the Stroop task, the letter-number sequencing and spatial span subtests of the Wechsler Memory Scale, and the Wisconsin Card Sorting Test (WCST). Results. Patients with schizophrenia (both cannabis users and non-users) showed significantly poorer performance across all neuropsychological tasks, relative to controls; however, there were no significant differences between schizophrenic cannabis users and schizophrenic non-users on any measures, with the exception of increased non-perseverative errors on the WCST in cannabis-using patients. Similarly, healthy cannabis users showed no significant differences from healthy non-users in any of the cognitive domains, with the exception of a schizophrenic-like increase in perseveration on the WCST. Conclusions. Amongst both healthy individuals and patients with schizophrenia there appears to be little difference in cognitive performance between cannabis users and non-users, suggesting that cannabis use has only subtle effects on the neurocognitive performance indices assessed here, which have been well established to be disturbed in schizophrenia.

Scholes-Balog KE; Martin-Iverson MT. Cannabis use and sensorimotor gating in patients with schizophrenia and healthy controls. Human Psychopharmacology: Clinical and Experimental 26(6): 373-385, 2011. (31 refs.)

Objective: Schizophrenia patients and healthy cannabis users show different attention-dependant alterations in prepulse inhibition (PPI). It is of interest then to examine PPI in patients with schizophrenia who use cannabis, given the hypothesized association between cannabis use and schizophrenia. Methods: Prepulse inhibition was measured in 34 healthy cannabis users, 32 healthy non-using controls, 20 patients with schizophrenia who were current cannabis users, and 44 non-using patients with schizophrenia. PPI was measured across a range of startling stimulus intensities, during two attention set conditions. Curves of best fit were fitted to the startle magnitudes, across the stimulus intensities. A number of reflex parameters were extracted from these logistic functions. Results: Similar to healthy cannabis users, cannabis-using patients showed altered PPI of Threshold, only when instructed to sustain attention to the auditory stimuli. Conversely, non-using patients with schizophrenia showed reduced PP of R(MAX) only when instructed to ignore the auditory stimuli. Conclusion Cannabis use in patients with schizophrenia is associated with a similar pattern of attention-dependant alterations in PPI to that observed in healthy cannabis users. This is different to those observed in patients with schizophrenia who do not use cannabis and may be as a result of a dysfunction of sustained attention.

Schroeder SA; Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. (review). Annual Review of Public Health 31: 297-314, 2010. (139 refs.)

Tobacco use exerts a huge toll on persons with mental illnesses and substance abuse disorders, accounting for 200,000 of the annual 443,000 annual tobacco-related deaths in the United States. Persons with chronic mental illness die 25 years earlier than the general population does, and smoking is the major contributor to that premature mortality. This population consumes 44% of all cigarettes, reflecting very high prevalence rates plus heavy smoking by users. The pattern reflects a combination of biological, psychosocial, cultural, and tobacco industry related factors. Although provider and patient perspectives are changing, smoking has been a historically accepted part of behavioral health settings. Additional harm results from the economic burden imposed by purchasing cigarettes and enduring the stigma attached to smoking. Tailored treatment for this population involves standard cessation treatments including counseling, medications, and telephone quitlines. Further progress depends on clinician and patient education, expanded access to treatment, and the resolution of existing knowledge gaps.

Sevy S; Robinson DG; Napolitano B; Patel RC; Gunduz-Bruce H; Miller R et al. Are cannabis use disorders associated with an earlier age at onset of psychosis? A study in first episode schizophrenia. Schizophrenia Research 120(1-3): 101-107, 2010. (68 refs.)

Introduction: The purpose of this study is to determine if an earlier age at onset of positive symptoms in schizophrenia is associated with cannabis use disorders (CUD). Methods: 49 first-episode schizophrenia subjects with CUD were compared to 51 first-episode schizophrenia subjects with no substance use disorders for demographic and clinical variables. A multivariate logistic regression was performed to determine the joint relationship between variables significantly associated with CUD on univariate testing and ascertain if these variables independently predict CUD. Significance level was set at p<0.05. Results: 74% of CUD subjects had the onset of CUD before the onset of positive symptoms. Compared to non-substance abusing subjects, CUD subjects were predominantly male, younger at study entry, had an earlier age at onset of positive symptoms, less educational attainment, a lower self-socioeconomic status, better premorbid childhood social adjustment, a trend for poorer premorbid childhood academic adjustment, less motor abnormalities but more severe hallucinations and delusions. In the multivariate analysis, only male gender, worse socioeconomic status, better premorbid childhood social adjustment, and more severe positive symptoms at study entry were associated with a lifetime history of CUD. Discussion: Although cannabis use precedes the onset of illness in most patients, there was no significant association between onset of illness and CUD that was not accounted for by demographic and clinical variables. Previous studies implicating CUD in the onset of schizophrenia may need to more comprehensively assess the relationship between CUD and schizophrenia, and take into account additional variables that we found associated with CUD.

Shibusawa T; Padgett D. The experiences of "aging" among formerly homeless adults with chronic mental illness: A qualitative study. Journal of Aging Studies 23(3): 188-196, 2009. (48 refs.)

Little is known about the life course of older adults with serious mental illness who have also been homeless. Using 44 life history interviews with 25 study participants ages 40 to 62, this study used case study and thematic analysis to examine the lived experience of such individuals as they enter their mid- and later-life years. Participants whose lives were marred by early-onset substance abuse, symptoms of mental illness and a descent into homelessness, spoke of an awareness of aging and premature mortality. Major themes that emerged were: (1) reflecting on losses, (2) growing older and wiser, (3) struggling with normality, (4) having space and time to reevaluate, and (5) awareness of the future and "time left." Life histories which focus on the person-in-context and their subjective experiences provide a viable research method to further the understanding of one of the most underserved and hardest-to-reach populations.

Slayter EM. Disparities in access to substance abuse treatment among people with intellectual disabilities and serious mental illness. Health & Social Work 35(1): 49-59, 2010. (60 refs.)

People with intellectual disabilities (ID) have experienced increasing levels of community participation since deinstitutionalization. This freedom has facilitated community inclusion, access to alcohol and drugs, and the potential for developing substance abuse (SA) disorders. People with ID, who are known to have high rates of co-occurring serious mental illness (SMI), may be especially vulnerable to the consequences of this disease and less likely to use SA treatment. Using standardized performance measures for SA treatment access (initiation, engagement), rates were examined retrospectively for Medicaid beneficiaries with ID/SA/SMI ages 12 to 99 (N = 5,099) and their counterparts with no ID/SA/SMI (N = 221,875). Guided by the sociobehavioral model of health care utilization, age-adjusted odds ratios and logistic regression models were conducted. People with ID/SA/SMI were less likely than their counterparts to access treatment. Factors associated with initiation included being nonwhite, living in a rural area, and not being dually eligible for Medicare; factors associated with engagement included all of the same and having a fee-for-service plan, a chronic SA-related disorder, or both. Social work policy and practice implications for improving the health of people with ID/SA/SMI through policy change, cross-system collaboration, and the use of integrated treatment approaches are discussed.

Smith MJ; Wang L; Cronenwett W; Goldman MB; Mamah D; Barch DM et al. Alcohol use disorders contribute to hippocampal and subcortical shape differences in schizophrenia. Schizophrenia Research 131(1-3): 174-183, 2011. (48 refs.)

Background: Alcohol abuse and dependence have been reported to exacerbate the clinical course of schizophrenia. However, the neurobiological basis of this co-morbid interaction is unknown. The aim of this study was to determine the relationship of co-morbid alcohol use disorder (AUD) with brain structure abnormalities in schizophrenia patients. Methods: T1-weighted magnetic resonance images were collected from schizophrenia patients without a history of any substance use disorder (SCZ_0, n = 35), schizophrenia patients with a history of AUD only (SCZ_AUD, n = 16), and a healthy comparison group without a history of any substance use disorder (CON, n = 56). Large-deformation, high-dimensional brain mapping was used to quantify the surface shapes of the hippocampus, thalamus, striatum, and globus pallidus in these subject groups. Analysis of variance was used to test for differences in surface shape measures among the groups. Results: SCZ_AUD demonstrated the greatest severity of shape abnormalities in the hippocampus, thalamus, striatum, and globus pallidus as compared to SCZ_0 and CON. SCZ_AUD demonstrated a combination of exaggerated shape differences in regions where SCZ_0 also showed shape differences, and unique shape differences that were not observed in SCZ_0 or CON. Conclusions: Shape differences in schizophrenia were compounded by a history of co-morbid AUD. Future research is needed to determine whether these differences are simply additive or whether they are due to an interaction between the underlying neurobiology of schizophrenia and alcoholism. The consequences of such shape differences for the clinical course of schizophrenia are not yet understood.

Srisurapanont M; Arunpongpaisal S; Wada K; Marsden J; Ali R; Kongsakon R. Comparisons of methamphetamine psychotic and schizophrenic symptoms: A differential item functioning analysis. (review). Progress In Neuro-Psychopharmacology & Biological Psychiatry 35(4): 959-964, 2011. (27 refs.)

The concept of negative symptoms in methamphetamine (MA) psychosis (e.g., poverty of speech, flatten affect, and loss of drive) is still uncertain. This study aimed to use differential item functioning (DIF) statistical techniques to differentiate the severity of psychotic symptoms between MA psychotic and schizophrenic patients. Data of MA psychotic and schizophrenic patients were those of the participants in the WHO Multi-Site Project on Methamphetamine-Induced Psychosis (or WHO-MAIP study) and the Risperidone Long-Acting Injection in Thai Schizophrenic Patients (or RLAI-Thai study), respectively. To confirm the unidimensionality of psychotic syndromes, we applied the exploratory and confirmatory factor analyses (EFA and CFA) on the eight items of Manchester scale. We conducted the DIF analysis of psychotic symptoms observed in both groups by using nonparametric kernel-smoothing techniques of item response theory. A DIF composite index of 0.30 or greater indicated the difference of symptom severity. The analyses included the data of 168 MA psychotic participants and the baseline data of 169 schizophrenic patients. For both data sets, the EFA and CFA suggested a three-factor model of the psychotic symptoms, including negative syndrome (poverty of speech, psychomotor retardation and flatten/incongruous affect), positive syndrome (delusions, hallucinations and incoherent speech) and anxiety/depression syndrome (anxiety and depression). The DIF composite indexes comparing the severity differences of all eight psychotic symptoms were lower than 0.3. The results suggest that, at the same level of syndrome severity (i.e., negative, positive, and anxiety/depression syndromes), the severity of psychotic symptoms, including the negative ones, observed in MA psychotic and schizophrenic patients are almost the same.

Stapleton JA. Commentary on Banham & Gilbody (2010): The scandal of smoking and mental illness. (editorial). Addiction 105(7): 1190-1191, 2010. (17 refs.)

Stein BD; Kogan JN; Sorbero M. Substance abuse detoxification and residential treatment among Medicaid-enrolled adults: Rates and duration of subsequent treatment. Drug and Alcohol Dependence 104(1-2): 100-106, 2009. (59 refs.)

Background: Substance use disorders are chronic disorders with substantial public health significance, yet the treatment provided is often episodic despite ongoing need. Among the more severely ill individuals requiring detoxification or residential treatment, little empirical information is available about rates and predictors of subsequent engagement in necessary subsequent treatment. Methods: Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of subsequent treatment engagement and retention following new episodes of detoxification or residential substance abuse treatment among 5670 Medicaid-enrolled adults during 2004-2006. Results: Slightly less than half (49%) of the sample received follow-up care within 30 days of discharge. Rates of follow-up were significantly higher in individuals with a serious mental illness, and significantly lower in African-American individuals, males, individuals with disabilities, and those who received detoxification without residential treatment. The mean duration of follow-up treatment was 84 days, and was longer among individuals with a serious mental illness and Caucasians. Even after controlling for individuals' sociodemographic and clinical characteristics, there was substantial variation in follow-up rates among discharging providers. Conclusion: The relatively low rates of follow-up care and relatively brief duration of treatment for many of those who received such follow-up care are concerning in a population receiving substance abuse detoxification or residential treatment. The markedly lower rates among those receiving detoxification alone without subsequent residential treatment and among those without a comorbid serious mental illness suggest that efforts specifically targeting those individuals may be of particular benefit.

Takeuchi T; Nakao M; Shinozaki Y; Yano E. Validity of the self-reported smoking status of schizophrenia patients, taking gender-related differences into consideration. International Journal of Psychiatry In Clinical Practice 14(4): 282-286, 2010. (15 refs.)

Objective. It is unclear whether self-reported smoking status reflects the true smoking status in schizophrenia patients. This study aims to evaluate the consistency in smoking status in schizophrenia patients, as determined using self-reported questionnaires and objective measurements, while considering gender-related differences. Methods. The study involved 158 Japanese schizophrenia patients (79 men and 79 women), who were diagnosed according to DSM-IV-TR criteria. The patients answered questions about their smoking status and daily cigarette consumption. The carbon monoxide (CO) level in the expired air was measured to confirm the self-reported answers. We descriptively analysed the data and assessed the proportion of results showing consistency between the self-reported smoking status and measured CO levels. Results. The self-reported smoking status was consistent with the objective measurement results in both genders. Among the various cut-off CO levels considered, 7 ppm was found to be the optimal level in both men and women. Conclusions. Our study showed that self-reporting is a reliable method for evaluating the smoking status of schizophrenia patients, regardless of gender. However, for precise assessment on the basis of CO levels in expired air, lower cut-off points may be better than the recommended ones.

Teferra S; Hanlon C; Alem A; Jacobsson L; Shibre T. Khat chewing in persons with severe mental illness in Ethiopia: A qualitative study exploring perspectives of patients and caregivers. Transcultural Psychiatry 48(4): 455-472, 2011. (27 refs.)

People with severe mental illness (SMI) in Ethiopia chew khat despite advice from their physicians to desist. We wanted to better understand their reasons for khat chewing, including any benefits that they might gain. A qualitative study was conducted involving patients with SMI and their caregivers in Butajira. Reasons given by patients as well as caregivers were more or less congruent: social pressure, a means for survival by improving function, combating medication side effects, to experience pleasure and curbing appetite. These findings will be of value to health workers, caregivers and policymakers alike in improving care and understanding for this patient group. Furthermore, our study indicates a role for future research to explore potentially beneficial effects of khat in this population.

Tenhula WN; Bennett ME; Kinnaman JES. Behavioral treatment of substance abuse in schizophrenia. Journal of Clinical Psychology 65(8): 831-841, 2009. (9 refs.)

Co-occurring substance use disorders are highly prevalent among individuals with schizophrenia and other serious and persistent mental illnesses (SPMI) and are associated with clinically significant consequences. A multifaceted behavioral treatment called Behavioral Treatment for Substance Abuse in Serious and Persistent Mental Illness (BTSAS) can reduce substance abuse in persons with SPMI. The key treatment strategies in BTSAS include a urinalysis contingency, short-term goal setting, training in drug refusal skills, psychoeducation about the impact of drug use, and relapse prevention training. A case example illustrating the application of BTSAS is presented and relevant clinical issues are discussed.

Vernex N; Dagher G; Touzeau D. Cannabis and premonitory symptoms of schizophrenia: What Is the time sequence? Heroin Addiction and Related Clinical Problems 11(3): 29-34, 2009. (13 refs.)

Nowadays, cannabis is the most widely used illegal drug in France. Epidemiological studies have shown that in schizophrenic patients the risk of developing cannabis dependence is six times what it is in the general population. However, debates on the real chronology of the appearance of psychiatric disorders and addictive cannabis behaviour are ongoing. The aim of this article is to try to find out how best to interpret the association of cannabis and premonitory symptoms through a review of the literature. Some recent longitudinal studies suggest a potential role for pre-existing troubles, taking the view that cannabis would only aggravate them and turn them into schizophrenic symptoms. By contrast, other studies propose a causal linkage as well as a dose-effect relationship between cannabis consumption and the appearance of schizophrenia. Conclusion: The methodology of these studies limits the possibility of a reverse causality. In addition, it must be noted that some research teams excluded from their cohort subjects who presented psychiatric disorders at entrance. Cannabis appears to be a risk factor for psychotic disorders, because it interacts with a pre-existing vulnerability. Neuroimagery research will make it possible to clarify the common cerebral mechanisms of cannabis and schizophrenia.

Vincenti A; Ventriglio A; Baldessarini RJ; Talamo A; Fitzmaurice G; Centorrino F. Characteristics and clinical changes during hospitalization in bipolar and psychotic disorder patients with versus without substance-use disorders. Pharmacopsychiatry 43(6): 225-232, 2010. (40 refs.)

Background: Co-morbid substance-use disorders (SUDs) are prevalent among patients with severe psychiatric disorders, but the characteristics of such patients remain incompletely defined, and their current treatments and responses, poorly documented. Methods: We evaluated the records of 481 consecutive inpatients diagnosed with DSM-IV bipolar or schizoaffective disorders, or schizophrenia, admitted to McLean Hospital in 2004 or 2009. Demographic and clinical characteristics, and treatments, were extracted from hospital and pharmacy records for bivariate and multivariate analyses. Results: SUD prevalence increased 1.84-times from 2004 (31.3%) to 2009 (57.6%). Patients with (n = 204) versus without co-morbid SUDs (n = 277) were similar in many respects, but in multivariate modeling, the following factors were more likely with SUD, in rank-order: co-morbid anxiety disorders > men more than women > greater prevalence in 2009 vs. 2004 > younger age > greater doses of mood-stabilizers > shorter hospitalization. Conclusions: Hospitalized patients with severe primary psychiatric disorders, and comorbid SUD were more likely to be young and have anxiety disorders, to receive more combinations and higher doses of mood-stabilizers, and show more improvement in impulsivity and hostility, but otherwise differed little in treatment-responses. Prevalence of SUD rose substantially in the past five years, with increased but largely unproved use of mood-stabilizers.

Volkow ND. Substance use disorders in schizophrenia-025EF: Clinical implications of comorbidity. (editorial). Schizophrenia Bulletin 35(3): 469-472, 2009. (29 refs.)

Nearly half of the people suffering from schizophrenia also present with a lifetime history of substance use disorders (SUD), a rate that is much higher than the one seen among unaffected individuals. This phenomenon suggests that the factors influencing SUD risk in schizophrenia may be more numerous and/or complex than those modulating SUD risk in the general population. It is critically important to address this comorbidity because SUD in schizophrenic patients is associated with poorer clinical outcomes and contributes significantly to their morbidity and mortality.

2009, Oxford University Press

Williams JM; Gandhi KK; Lu SE; Kumar S; Shen JW; Foulds J et al. Higher nicotine levels in schizophrenia compared with controls after smoking a single cigarette18. Nicotine & Tobacco Research 12(8): 855-859, 2010. (18 refs.)

Introduction: The increase in blood nicotine after smoking a single cigarette is nicotine boost. We hypothesized that smokers with schizophrenia (SCZ) have a greater nicotine boost than controls without this disorder. Methods: Twenty-one subjects (11 SCZ and 10 controls, CON) had repeated venous blood sampling before, during, and after smoking a single cigarette after 12-hr abstinence to measure nicotine concentrations. Blood samples were drawn at baseline (before smoking) and 1, 2, 4, 6, 8, 10, 20, 30, 60, 90, and 120 min after the first puff. Groups were similar in baseline characteristics, including gender and level of dependence, and all smoked 20-30 cigarettes/day. Area under the serum nicotine concentration-time curve (AUC(20)) was calculated for time up to 20 min after the start of smoking. Results: The mean difference in AUC20 was significantly greater for SCZ versus CON (135.4 ng-min/ml; 95% CI = 0.45-283.80). The shape of the nicotine concentration-time curve for SCZ was significantly different compared with controls (p < .01). Nicotine boost in the first 4 min of smoking was higher in SCZ versus CON (25.2 vs. 11.1 ng/ml, p < .01) with no difference in the total time spent smoking. Discussion: This technique improves on methods, which draw only two blood specimens to assess nicotine intake. Understanding how nicotine boost differs in SCZ from CON may explain high levels of addiction and low success in cessation in smokers with SCZ.

Williams JM; Zimmermann MH; Steinberg ML; Gandhi KK; Delnevo C; Steinberg MB et al. A comprehensive model for mental health tobacco recovery in New Jersey. Administration and Policy in Mental Health and Mental Health Services Research 38(5): 368-383, 2011. (118 refs.)

Despite the high prevalence of tobacco use, disproportionate tobacco consumption, and excess morbidity and mortality, smokers with mental illness have reduced access to tobacco dependence treatment across the health care spectrum. We have developed a comprehensive model for Mental Health Tobacco Recovery in New Jersey (MHTR-NJ) that has the overarching goal of improving tobacco cessation for smokers with serious mental illness. Important steps involve engaging patients, professionals and the community to increase understanding that addressing tobacco use is important. In addition to increasing demand for tobacco treatment services, we must educate mental health professionals in evidence-based treatments so that patients can seek help in their usual behavioral health care setting. Peer services that offer hope and support to smokers are essential. Each of the policy or cessation initiatives described address the two core goals of this model: to increase demand for tobacco cessation services for mentally ill smokers and to help more smokers with mental illness to quit. Each has been pilot tested for feasibility and/or effectiveness and revised with feedback from stakeholders. In this way this implementation model has brought together academics, clinicians, administrators and mental health consumers to develop tobacco programming and policy that has been tested in a real world environment and serves as a model for other states.

Wilson DC; Crisanti AS. Psychometric properties of the Dual-Disorder Treatment Fidelity Scale: Inter-rater reliability and concurrent validity. Community Mental Health Journal 45(3): 171-178, 2009. (20 refs.)

Psychometric properties of the Dual-Disorder Treatment Fidelity Scale (Mueser et al. Integrated treatment for dual disorders: A guide to effective practice, 2003) were evaluated. Reliability was assessed through measures of inter-rater agreement, and validity was assessed through a concurrent known groups validation procedure. Two raters assessed three community mental health center (CMHC) and three specialized dual diagnosis (DDE) programs for fidelity; inter-rater agreement was good. Total fidelity scores did not distinguish between CMHC and DDE program types; however, a cluster analysis revealed concurrent validity based on the item level ratings. Conclusions drawn from item level ratings appear valid; the validity of conclusions based on total scores remains unsupported.

Woznica AA; George TP. Exploiting nicotinic receptor mechanisms for the treatment of schizophrenia and depression. Journal of Dual Diagnosis 5(2): 159-167, 2009. (30 refs.)

Smoking rates are higher in persons with schizophrenia (SZ; 58%-88%) and major depressive disorder (MDD; 40%-60%) compared to the U. S. general population (similar to 23%). Nicotinic acetylcholine receptors (nAChRs) are the brain receptors for nicotine. SZ and MDD are nicotine-responsive neuropsychiatric disorders. Thus, it is hypothesized that the higher rates of smoking in the SZ and MDD populations can be attributed to the pathophysiology of these disorders. Knowledge of nAChR functioning can be exploited in therapeutics for treating both the addiction and clinical aspects of these disorders. This article reviews the neurobiology of nAChR and biological dysregulation inherent in SZ and MDD. In addition, manipulation of nAChRs with appropriate agonists and antagonists is discussed. Specifically, nAChRs can be stimulated to improve cognitive deficits associated with SZ and blocked for the treatment of selective serotonin reuptake inhibitor-refractory major depression; a combination of agonism and antagonism may assist with smoking cessation in SZ populations. This knowledge has significant implications for further development of pharmacotherapies for treatment of SZ and MDD symptoms and for smoking cessation in these disorders.

Zhang XY; Li CB; Li M; Zheng YL; Zhang CX; Yan QZ et al. Smoking initiation and schizophrenia: A replication study in a Chinese Han population. Schizophrenia Research 119(1-3): 110-114, 2010. (29 refs.)

Schizophrenia is associated with a greater probability of ever smoking daily and with higher rates of initiation of daily smoking after age 20 in Caucasian populations. The aims of the current study were to replicate that schizophrenia is associated with smoking and higher risk of initiating daily smoking before schizophrenia starts among a large sample of male Chinese patients. A survival analysis of onset age for daily smoking compared 776 DSM-IV male inpatients with schizophrenia to 560 male controls. The results showed that the cumulative hazard curves for age of smoking initiation in schizophrenia and controls were significantly different (p<0.001), even after controlling for education (p<0.001). After excluding the patients who started smoking within 5 years before schizophrenia started, the cumulative hazard curve for schizophrenia was significantly different from ever-smoked controls (p<0.001), even after adjusting for education (p<0.001). These findings suggest that schizophrenic patients have a higher risk of starting daily smoking suggesting that vulnerability to schizophrenia may be associated with a higher risk of becoming a daily smoker.

Zhang XY; Xiu MH; Chen DC; Yang FD; Wu GY; Lu L et al. Nicotine dependence and serum BDNF levels in male patients with schizophrenia. Psychopharmacology 212(3): 301-307, 2010. (63 refs.)

Schizophrenia is associated with a significantly high prevalence of smoking. Upregulation of neurotrophins by nicotine is well established. Accumulating evidence shows that brain-derived neurotrophic factor (BDNF) may be involved in the pathophysiology of schizophrenia. The purposes of this study were to compare BDNF levels in smokers to nonsmokers with schizophrenia and examine the association between BDNF levels and psychopathological symptoms. Serum BDNF levels were measured in 139 male inpatients with DSM-IV schizophrenia: 102 smokers and 37 nonsmokers. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). The positive PANSS symptoms were lower in smokers than in nonsmokers, while the negative symptoms were lower in those who smoked more cigarettes. BDNF levels were significantly higher in smokers than in nonsmokers (p < 0.05). Higher BDNF levels correlated with fewer negative symptoms and with smoking more cigarettes. The fewer positive symptoms in smokers and fewer negative symptoms in those who smoked more cigarettes may be associated with nicotine-induced upregulation of BDNF.

zSchiffer B; Muller BW; Scherbaum N; Forsting M; Wiltfang J; Leygraf N et al. Impulsivity-related brain volume deficits in schizophrenia-addiction comorbidity. Brain 133(Part 10): 3093-3103, 2010. (54 refs.)

Despite a high prevalence of schizophrenia patients with comorbid substance abuse, little is known about possible impacts on the brain. Hence, our goal was to determine whether addicted and non-addicted schizophrenic patients suffer from different brain deficits. We were especially interested to determine if grey matter volumes were affected by impulsivity. We hypothesized that (comorbid) substance abuse would be associated with enhanced impulsivity and that this enhanced impulsivity would be related to grey matter volume deficits in prefrontal areas. We employed a voxel-based morphometry approach as well as neuropsychological assessment of executive functions and trait impulsivity in 51 participants (age range 23-55). The schizophrenia group comprised 24 patients (12 patients with paranoid schizophrenia and 12 with additional comorbid substance use disorders). The comparison group comprised 27 non-schizophrenic individuals, matched by age and education (14 healthy individuals and 13 patients with substance use disorders). Total grey matter volume deficits were found in all patient groups as compared with healthy controls but were largest (similar to 8%) in both addicted groups. While grey matter volume losses in lateral orbitofrontal and temporal regions were affected by schizophrenia, volume decreases of the medial orbitofrontal, anterior cingulate and frontopolar cortex were associated with addiction. Compared with non-addicted schizophrenics, comorbid patients showed significant volume decreases in anterior cingulate, frontopolar and superior parietal regions. Additionally, they showed an increased non-planning impulsivity that was negatively related to grey matter volumes in the same regions, except for parietal ones. The present study indicates severe grey matter volume and functional executive deficits in schizophrenia, which were only partially exacerbated by comorbid addiction. However, the relationship between non-planning impulsivity and anterior cingulate and frontopolar grey matter volumes points to a specific structure-function relationship that seems to be impaired in schizophrenia-addiction comorbidity.

Zullino DF; Manghi R; Rathelot T; Khan R; Khazaal Y. Cannabis causes schizophrenia? So does nicotine. (editorial). Addiction Research & Theory 18(6): 601-605, 2010. (28 refs.)

The article presents the authors' concern regarding their study on the correlation between cannabis use and schizophrenia as well as its neurological soft signs. They stress that if cannabis is viewed as a cause of schizophrenia, then the same should apply to tobacco and vice versa. Moreover, they propose an alternative hypothesis to rationalize this possible correlation.